Clinical Applications of Neuromuscular Techniques The Lower Body Volume 2

THE LUMBAR SPINE 275 M P Innervation: Ventral and dorsal rami of spinal nerves (11-4) (respectively) Muscle typ e : Not established Function: Lateral flexion of the spine, although this function is debated by Bogduk (1997) Synergists: Interspinales, rotatores, multifidi Antagonists: Lateral flexors of the contralateral side Indications for treatment Restriction in lateral flexion Figure 1 0.41 The short intersegmental muscles. ITLV: Specia l notes intertransversarii laterales ventrales; ITLD: intertransversarii laterales dorsales; ITM: intertransversarii mediales; IS: interspinales; AP: These short, laterally placed muscles most likely act as accessory process; MP: mamillary process; MAL: mamillo-accessory postural muscles which stabilize the adjoining vertebrae ligament (reproduced with permission from Bogduk (1 997) ). during movement of the spinal column as a whole. The pattern of movement of intertransversarii is unknown, Figure 1 0.42 The beveled pressure bar is used between spinous but thought to be lateral flexion, although Bogduk (1 997) processes of contiguous vertebrae. The bodyCushionTM by Body suggests they may act as proprioceptive transducers, Support Systems Inc. is especially useful in helping to separate the monitoring movements to provide feedback which will spinous processes slightly through supportive positioning of the influence surrounding tissues. thoracic and lumbar regions. See contact details on p. 1 01 . These muscles are difficult to reach and attempts to Intertransversarii lateralis and mediales palpate them may not be fruitful. Positional release and muscle energy techniques may prove useful in releasing Attachments: Laterally and medially placed muscle pairs these deeply placed tissues. which join the transverse processes of contiguous vertebrae \" \" MET for multifidi and other small, deep muscles of the low back • The protocols for MET application to local spinal and paraspinal muscles, which are often impossible to identify, specifically require generalized description of methods which can be applied to any local area of ten­ sion, induration and /or fibrocity. • Tense or restricted soft tissues should be identified by palpation, by loss of range of motion or by association with a vertebra which is tender when its spinous process is lightly tapped. • Manual stretching of the taut fiber is usually applied across the fiber direction if this can be identified . This might either involve a 'C-shaped form, where the tissue is being 'bent', or an '5' shape in wluch the fibers are being stretched in two directions simultaneously by the prac­ titioner's two thumbs. • Once it has been decided that some degree of local stretching release is appropriate, the fibers should be eased toward a position where the slack is removed from the elastic components. • Once the barrier has been engaged the patient is asked to introduce a local isometric contraction into the tissues being treated for 5-7 seconds, following which the tissues are stretched beyond the previous resistance barrier and held for up to 30 seconds to encourage lengthening.

276 CLINICAL APPLICATION OF NMT VOLUM E 2 Digitations of serratus anterior Latissimus dorsi Figure 1 0.43 Creating an 'S'-shaped bend in tissues to effect Rectus myofascial release (reproduced with permission from Chaitow (2001 ) ). abdominis �--'l!--=-;:+' - Obliquus Internus Figure 1 0.44 Creating a 'C'-shaped bend in tissues to effect Intercostalis lengthening (reproduced with permission from Chaitow (200 1 ) ). internus of 1 0th intercostal space This may be accomplished by an active range of motion if fiber has been clearly identified or by a precisely placed Figure 1 0.45 Muscles of the abdominal wall. Obliquus externus 'miniature' myofascial release if direction of fiber has abdominis has been removed (except for rib attachments) to reveal been determined. obliquus internus abdominis. The anterior lamina of the rectus sheath has been removed to reveal the rectus abdominis muscle (reproduced • This approach can be used paraspinally or on a very with permission from Grays anatomy (1 995) ). localized level to free any shortened soft tissue structures. segmental stability (Hodges 1999). The rectus abdominis, PRT for small deep muscles of the external and internal obliques and transversus abdominis low back (Induration technique) are also involved in respiration due to their role in positioning the abdominal viscera to provide stabilizing Treatment of small localized muscular stresses in the resistance to the diaphragm as well as depression of the paraspinal muscles, using PRT methodology, is elegantly lower ribs, thereby assisting in forced expiration, especially accomplished by means of an SCS derivative, induration coughing. technique. This extremely gentle method is fully explained and described in Volume I , Fig. 14.15, p. 444. The muscles of the abdominal wall can be subdivided into medial muscles (rectus abdominis and pyramidalis) Muscles of the abdominal wall (Fig. 1 0.45) and the superficial lateral muscles (obliquus externus abdominis, obliquus internus abdominis and transversus Like the erector system of the posterior thorax, the abdominis). These muscles and their ensheathing fascia abdominal muscles play a significant role in positioning form a complex supportive tensional network for the the thorax and in rotating the entire upper body. They lower back (see Fig. 1 0.22). Spinal stability depends upon (particularly transversus abdominis) are also now known these tensional elements as well as contributions from the to play a key part in spinal stabilization and inter- deep lateral abdominal muscles (quadratus lumborum and psoas) and the paraspinal muscles discussed previously.

THE LUMBAR SPINE 277 Posteriorly, the fascia of the superficial lateral Box 1 0.8 Abdominal palpation: is the pain in the muscle or an abdominal muscles contributes to the thoracolumbar organ? fascia, as previously discussed on p. 248. Anteriorly, these muscles give rise to the rectus sheath and the linea alba . Since there is no immediately accessible underlying osseous Regarding the fascial sheath of the superior portion of structure available to allow compression of the musculature on rectus abdominis, Kapandji (1 974) notes that the external much of the soft tissues of the abdomen, there is a need for oblique contributes to the anterior aspect while strategies which distinguish palpated pain occurring as a result transversus abdominis contributes 'to the posterior of visceral dysfunction or disease, from that being produced in portion. The internal oblique, which is sandwiched surface tissues. Two protocols are suggested. between the other two muscles, splits at the lateral border of rectus abdominis to wrap around both anteriorly and • When a local area of abdominal pain is noted while using posteriorly, thereby 'ensheathing' the rectus, as its fascia NMT or any other palpation method, the tissues should be blends with that of the other two lateral muscles to form firmly compressed by the palpating digit, sufficient to produce the rectus sheath. The bilateral sheaths merge at the anterior local pain and referred pain (if a trigger is involved) but not mid-line to form the linea alba. Below the umbilicus, at enough to cause distress. The supine patient should then be the arcuate line, the posterior aspect of the rectus sheath asked to raise both heels several inches from the table. As this ends and the rectus abdominis perforates the transversus happens there will be a contraction of the abdominal muscles abdominis to lie on the posterior surface of its apo­ and compression of their fibers against the palpating digit. The neurosis. In this way, from the arcuate line caudally, the pain may increase or remain as before, particularly if trigger transversus abdominis contributes to the anterior rectus points are involved. If pain decreases or vanishes on raising of sheath and the rectus is covered posteriorly only by the heels, the site of the pain is beneath the muscle (which has transversalis fascia. lifted the palpating digit off the viscera) and points toward a visceral source of the pain. Directly deep to the abdominal muscles lies much of the abdominal viscera. Trigger points located in the • If single-digit (finger or thumb) pressure is noted as painful abdominal muscles have been shown to initiate a number on a part of the abdominal wall musculature (with or without of somatovisceral responses involving organs from the referral) and there is an increased level of pain noted on urinary, digestive and reproductive systems (Simons et al sudden release of the pressure (known as rebound pain), this 1 999) as well as pain into the mid-thorax, sacroiliac and suggests intraabdominal dysfunction or pathology (Thomson & lower back regions, chest, abdomen, groin and (crossing Francis 1 977). the mid-line) into the contralateral side of the chest and abdomen. It is, of course, possible for there to be a problem in the viscera as well as in the abdominal wall. The tests therefore offer clues The abdominal musculature has a high propensity for but not absolute findings and, when positive, suggest strong referral patterns into the viscera (Simons et al professional referral to be appropriate. 1 999) and the viscera is capable of producing varying degrees of pain in somatic tissues (Rothstein et al 1991, function has been restored. (See Box 1 0.9 regarding Simons et al 1 999) . When pain is reported in the abdominal reflexes and Box 10.10 for a list of known abdominal region, it is imperative that the practitioner somatovisceral referral patterns.) consider possible pathological conditions of the viscera as well as trigger point referral patterns of the abdominal Causes of abdominal triggers (and sometimes lower back) muscles. Attempts should be made to differentiate between viscerally produced patterns Soft tissue changes and triggers in the abdominal muscu­ of referral and those produced by myofascial trigger lature are affected by very much the same factors that points (see Box 1 0.8). Simons et al ( 1 999) report: produce 'stress' anywhere else in the musculoskeletal system: Activation and perpetuation of trigger points in the abdominal wall musculature secondary to visceral disease represents a • postural faults (and breathing dysfunction) viscerosoma tic response . . . [these] visceral diseases . . . include • overuse and strain - occupational, sporting, patterns peptic ulcer, intestinal parasites, dysentery, ulcerative colitis, diverticulosis, diverticulitis, and cholelithiasis. Once activated, of use, overload, repetition of movement TrPs may then be perpetuated by emotional stress, • trauma occupational strain, paradoxical respiration, faulty posture, • environmental stressors, such as cold and damp and overenthusiasm for misdirected 'fitness' exercise. • nutritional deficiencies • surgery (another form of direct trauma) These somatically produced trigger points can remain • viscerosomatic influences as a result of visceral long after the visceral condition has improved and should be considered when pain persists after organ disease • emotional stress. Scars from previous surgeries may be the site of for­ mation of connective tissue trigger points (Simons et al 1999). After sufficient healing has taken place, these incision sites can be examined by pinching, compressing and rolling the scar tissue between the thumb and finger to

278 CLINICAL APPLICATION OF NMT VOLUM E 2 Box 1 0.9 Different views of abdominal reflex areas with one finger over one or both levator muscles; 5) single-finger or cotton tip applicator pressure lateral to the cervix; 6) single-finger A number of clinicians and workers have identified reflex areas or cotton tip applicator pressure over vaginal cuff scar tissue, more associated with the abdominal region including: than 3 months after hysterectomy; 7) single-finger pressure on tissue over the dorsal sacrum'. Slocumb also noted that: 'there was • Mackenzie (1 909) demonstrated a clear relationship between often observed an association of these pain points within a single the abdominal wall and the viscera. These reflex patterns vary in dermatome'. The results of treating a series of patients with individual cases but it is clear that the majority of the organs are symptoms of chronic pelvic pain by means of trigger point able to protect themselves by producing contraction, spasm and deactivation (Slocumb used anesthetic injections to achieve this) hyperesthesia of the overlying, reflexively related muscle wall (the were 'successful response in 89.3% of 1 31 patients' with nearly myotome) which is often augmented by hyperesthesia of the 70% followed up for 6 months or more. overlying skin (the dermatome) (see Volume 1 , Fig. 6.3, p. 76 for depiction of viscerosomatic reflexes). • Baldry (1 993) details a huge amount of research which validates the link (a somatovisceral reflex) between abdominal • Gutstein ( 1 944) noted trigger 'areas' in the sternal, parasternal trigger points and symptoms as diverse as anorexia, flatulence, and epigastric regions and the upper portions of the rectus, all nausea, vomiting, diarrhea, colic, dysmenorrhea and dysuria. Pain relating to varying degrees of retroperistalsis. He also noted that of a deep ach ing nature or sometimes of a sharp or burning type colonic dysfunction related to triggers in the mid and lower rectus are reported as being associated with this range of symptoms, abdominis muscle. These were all predominantly left-sided. Other which mimic organ disease or dysfunction (Melnick 1 954, Ranger symptoms which improved or disappeared with the obliteration of 1 97 1 , Theobald 1 949). Baldry ( 1 993) has further summarized the these triggers include excessive appetite, poor appetite, flatulence, importance of this region as a source of considerable pain and nervous vomiting, nervous diarrhea, etc. The triggers were always distress involving pelvic, abdominal and gynecological symptoms. tender spots, easily found by the palpation and situated mainly in He says: 'Pain in the abdomen and pelvis most likely to be helped the upper, mid and lower portions of the rectus abdominis muscles, by acupuncture is that which occurs as a result of activation of over the lower portion of the sternum and the epigastrium including trigger points in the muscles, fascia, tendons and ligaments of the the xyphoid process and the parasternal regions. anterior and lateral abdominal wall, the lower back, the floor of the pelvis and the upper anterior part of the thigh. Such pain, however, • Fielder & Pyott ( 1 955) describe a number of reflexes, which is all too often erroneously assumed to be due to some intra­ were claimed to relate to adhesion formation, occurring in the abdominal lesion, and as a consequence of being inappropriately connective tissue supporting and surrounding the large bowel. treated is often allowed to persist for much longer than is These could be localized by deep palpation and treated by specific necessary'. Note: If we replace the word 'acupuncture' (or the deep soft tissue release techniques (Chaitow 1 996a). injection methods of Slocumb described above) with the term 'appropriate manual methods', we can appreciate that a large • Chapman (see Owen 1 963) identified what he termed amount of abdominal and pelvic distress is remediable via the neurolymphatic reflexes, many of which were located in the methods outlined in this text. thoracic and abdominal regions. Travell & Simons (1 983) identified trigger points in similar locations in the abdominal musculature and • Many of Jones's (1 981 ) tender points, as used in strain­ a range of acupuncture/acupressure/tsubo points have also been counterstrain techniques, are found in the abdominal region mapped in these tissues. To what extent Gutstein's myodysneuric specifically relating to those low back strains which occur in a pOints are interchangeable with Chapman's reflexes or Fielder's flexed position. reflexes or other systems of reflex study (e.g. acupuncture or Tsubo points (Serizawa 1 976)) or with Travell's triggers, and to The characteristics of nearly all these myriad 'point' systems are what extent these involve Mackenzie's findings, is a matter of that the dysfunctional tissues are palpable, sensitive and discrete - conjecture. sometimes 'stringy', sometimes edematous but always 'different' from surrounding normal tissues - and they are usually sensitive to • Slocumb (1 984). working at the Department of Obstetrics and pressure or pinching compression of the overlying skin. Apart from Gynecology, University of New Mexico Medical School, described pain, often of a deep aching nature, the reflex influences seem to trigger points which were causing chronic pelvic pain, many of involve interference or modifications of the functional integrity of which were located in the abdominal wall. Slocumb found that local areas as well as reflexively with normal physiological function deactivation of such triggers frequently removed symptoms which on a neural, circulatory and lymphatic level, sometimes mimicking had been present for years and which had at times resulted in serious pathological conditions. Our clinical experience suggests abortive surgical investigation. He noted an overlap of referral that these areas of dysfunction will often yield to simple NMT soft patterns from a variety of locations: 'The same pain sensation was tissue manipulative techniques (such as ischemic compression, reproduced by pressure over localized points in several tissues lengthening and draining procedures). seemingly anatomically unrelated. . .for example, 1) pinching the skin over the lower abdominal wall; 2) single-finger pressure in one reproducible abdominal wall location [trigger point]; 3) single-finger pressure on tissue overlying the pubic bone; 4) lateral pressure examine for evidence of trigger points. These tissues nodes. Properly applied lymph drainage techniques may frequently respond well to repeated rolling and sustained reestablish lymph movement and, in some cases, can compression, which can usually be repeated at home by reroute the lymphatic flow around the scar tissues. the patient. One author (JD) has had substantial success in reducing scar tissue-referred pain in scars of recent Differential assessment is obviously important in a origin as well as older scar tissue. region housing so many vital organs and attention to the overall pattern of symptom presentation is critical. The Transverse abdominal scars, such as those usually information discussed in this chapter regarding organ created by caesarean section and hysterectomy, may pathologies is intended to offer 'red flags' to the prac­ impede lymphatic flow in the lower abdominal region titioner to proceed with caution or, in some cases, not to which, in this area, flows downward to the inguinal proceed at all until a clear diagnosis has been given. This

THE LUMBAR SPINE 279 Box 1 0. 1 0 Somatovisceral patterns o f the abdominal muscles Innervation: 7th-12th intercostal nerves Muscle type: Phasic (type 2) with tendency to inhibition, The musculature of the abdominal wall is well known for its numerous referral patterns which mimic, exacerbate or form as weakening a result of visceral disease. This list, while not exhaustive, Function: When contracting unila terally, it contra­ should be considered with any abdominal pain or suspected organ dysfunction. Organ pathologies should also be ruled out laterally rotates the thoracolumbar spine and /or flexes by a qualified clinician since these triggers are often secondary the trunk ipsilaterally. Bilateral contraction produces to underlying organ pathology. See also Box 1 0. 1 for details anterior flexion of the trunk, support and compression regarding viscerosomatic referrals as well as Volume 1 , Fig. 6.3, of the abdominal viscera, anterior support of the spinal p. 76, for common pain-referred zones of various organs. column (see discussions regarding thoracolumbar fascia), and anterior stabilization of pelvic position Simons et al (1 999) discuss the following somatovisceral (decreasing lordosis). Also assists in forced expiration responses from abdominal musculature and note that injection by depressing lower ribs of the target referral zone of an organ may offer symptomatic Synergists: For rota tio n : ipsila teral deep paraspinal relief. They caution, however: 'Relief of pain in this way does not muscles and contralateral serratus posterior inferior guarantee that the pain site is the site of origin'. We have also and internal obliques seen many of these patterns in clinical practice and fully agree For lateral flexion: ipsilateral internal oblique, quadratus with the warning to be constantly aware of both the possibility lumborum, iliocostalis of underlying primary visceral involvement and the potential that For compression and support of abdominal viscem: obliquus the diagnosis may be significantly confused by trigger points internus abdominis, transversus abdominis, rectus with powerful visceral-stimulating potential. Although conclusive abdominis, pyramidalis, quadratus lumborum and research has not yet confirmed this, less intense referral diaphragm patterns could conceivably produce less abrupt symptoms than For flexion of spinal column: rectus abdominis, obliquus those listed here, resulting perhaps only in sluggish digestion, intenms abdominis and, depending upon spinal constipation, i rregular menses, endocrine imbalances or other position, psoas bothersome but not highly noxious or definitive symptoms. For forced expiration: rectus abdominis, obliquus intenms abdominis, transversus abdominis, internal intercostals • Projectile vomiting (except parasternal internal intercostals) and (with • Anorexia increased demand) the latissimus dorsi, serratus pos­ • Nausea terior inferior, quadratus lumborum and iliocostalis • Intestinal colic lumborum • Urinary bladder and sphincter spasm Antagonists: To rotation: contralateral deep paraspinal • Dysmenorrhea muscles and ipsilateral serratus posterior inferior and • Pain symptoms mimicking those of appendicitis and internal obliques To lateral flexion : contralateral quadratus lumborum, cholelithiasis iliocostalis, obliquus externus and intenms abdominis • Symptoms of burning, fullness, bloating, swelling or gas To compression and support of abdominal viscera: gravity To flexion of spinal column: paraspinal muscles (Gutstein 1 944) To forced expiration: diaphragm, scalene, parasternal • Heartburn and other symptoms of hiatal hernia internal intercostals, levator costorum, upper and • Urinary frequency lateral external intercostals and (with increased • Groin pain demand) the sternocleidomastoid, upper trapezius, • Chronic diarrhea serratus anterior, serratus posterior inferior, pectoralis • Pain when coughing major and minor, latissimus dorsi, erector spinae, • Belching subclavius and omohyoid • Chest pain which is not cardiac in origi n • Abdominal cramping Obliq uus internus abdominis • Colic in infants as well as adults Attachments: From the cartilages of the last 3-4 ribs, the information is not intended to be diagnostic itself, linea alba and the arch of the pubis (conjoined with especially when diagnosis lies outside the scope of the transversus abdominis) to converge laterally onto the practitioner's license and /or training. When any doubt lateral half to two-thirds of the inguinal ligament, the exists as to the primary origin of the condition (not to be anterior two-thirds of the iliac crest and portions of confused with secondary symptom-producing evidence), the thoracolumbar fascia expert diagnostic investigation is urged. This is true for all body regions but can be of crucial consideration in the abdominal region where underlying conditions can be life threatening. Obliquus externus abdominis Attachments: Outer surface and inferior borders of 5th-12th ribs (interdigitating with serratus anterior and latissimus dorsi) to join the broad abdominal aponeurosis (forming the linea alba) and to the anterior half of the iliac crest

280 CLINICAL APPLICATION OF NMT VOLUME 2 Innervation: 7th-12th intercostal nerves and iliohypo­ Intercostales interni Intercostales externi gastric and ilioinguinal nerves (Ll) Position --�-. �-=:-y:--I Muscle type: Phasic (type 2), with tendency to inhibition, of lateral weakening border of Function: Unilaterally, ipsilaterally rotates the thora­ rectus columbar spine, ipsilaterally flexes the trunk laterally. abdominis Bilateral contraction produces anterior flexion of the spine, support and compression of the abdominal viscera. Cut edge ---,,-;' -;-.... Thoraco­ Also assists in forced expiration of posterior lumbar Synergists: For rotation: contralateral deep paraspinal lamina of =-=-- Transversus muscles and obliquus externus abdominis and ipsi­ aponeurosis abdominis lateral serratus posterior inferior For lateral flexion: ipsilateral obliquus externus abdominis, of internal 1---=-= ==..,--:-:-- Cut edge of quadratus lumborum, iliocostalis oblique For compression and support of abdominal viscera: obliquus internal externus abdominis, transversus abdominis, rectus Posterior ---\"f.,-­- oblique abdominis, pyramidalis, quadratus lumborum and aponeurosis diaphragm lamina of For flexion of spinal column: rectus abdominis, obliquus sheath of Arcuate line externus abdominis a nd, depending upon spinal Transversalis fascia position, psoas rectus Rectus abdominis For forced expiratio n : rectus abdominis, obliquus abdominis externus abdominis, transversus abdominis, some of the internal intercostals and (with increased demand) Cut edge of -{___ the latissimus dorsi, serratus posterior inferior, quadratus lumborum and iliocostalis lumborum aponeurosis of external Antagonists: To rota tio n : ipsilateral deep paraspinal oblique muscles and obliquus externus abdominis and contralateral serratus posterior inferior Conjoint tendon Transversalis fascia To lateral flexion : contralateral obliquus externus and Figure 1 0.46 . The left transverse abdominis (reproduced with internus abdominis, quadratus lumborum, iliocostalis permission from Gray's anatomy ( 1 995) ) . To compression and support of abdominal viscera: gravity To flexion of spinal column: paraspinal muscles . Function: Constricts abdominal contents; assists in To forced expiration: diaphragm, scalene, parasternal forced expiration internal intercostals, levator costorum, upper and lateral external intercostals and (with increased Synergists: For compression and support of abdominal demand) the sternocleidomastoid, upper trapezius, viscera: obliquus externus abdorninis, obliquus internus serratus anterior, serratus posterior inferior, pectoralis abdominis, rectus abdominis, pyramidalis, quadratus major and minor, latissimus dorsi, erector spinae, lumborum and diaphragm subclavius and omohyoid For forced expiration: rectus abdominis, obliquus externus abdominis, obliquus inten1Us abdominis, some of the Transverse abdominis (Fig. 1 0.46) internal intercostals and (with increased demand) the latissimus dorsi, serratus posterior inferior, quadratus Attachments: From the inner surface of ribs 7-1 2, the lumborum and iliocostalis lumborum deep layer of the thoracolumbar fascia, inner lip of iliac crest, ASIS and inguinal ligament to merge into its Antagonists: To compression and support of abdominal aponeurosis and participate in the formation of the viscera : gravity rectus sheath, which merges at the mid-line to form the To forced expiration: diaphragm, scalene, parasternal linea alba internal intercostals, levator costorum, upper and lateral external intercostals and (with increased Innervation: 7th-1 2th intercostal nerves and iliohypo­ demand) the sternocleidomastoid, upper trapezius, gastric and ilioinguinal nerves (Ll) serratus anterior, serratus posterior inferior, pectoralis major and minor, latissimus dorsi, erector spinae, Muscle type: Phasic (type 2), with tendency to inhibition, subclavius and omohyoid weakening

THE LUMBAR SPINE 281 Indications for treatment of all lateral abdominals contralateral abdomen and chest. They also refer into the groin and testicular region and into the viscera, as • Postural distortion of pelvis (see also Chapter 11 for previously discussed, causing (among other conditions) discussions of pelvic osseous dysfunctions) chronic diarrhea (Simons et a1 1 999) (Figs 1 0.47-49). • Rotoscoliosis Stretching and strengthening of the lateral abdominal • Dysfunctional gaiting muscles are indicated in many respiratory and postural • Loss of abdominal tone dysfunctions as these muscles are often significantly • Post abdominal surgery involved. Lack of tone in these muscles may contribute to • Pain in chest or abdomen lower back problems, as has been discussed within this • Pain into lower abdomen, inguinal area and / or chapter. Rehabilitation and strengthening of these muscles are critical to spinal stability and details are crossing mid-line to radiate into chest or into upper offered in Chapter 7, as a self-applied abdominal muscle or lower abdomen rehabilitation. • Testicular pain • Assorted gastrointestinal symptoms (gas, bloating, NMT (and MFR) for lateral belching, heartburn, etc.) abdominal muscles • Vomiting, diarrhea and other symptoms of visceral pathology (see Box 1 0 . 1 0 for a more complete visceral The patient is in a sidelying position with his head referral pattern list) supported in neutral position. A bolster is placed under the contralateral waist area so as to create elongation of Special notes the side being treated. The patient's uppermost arm is abducted to lie across the side of his head and the upper­ The diagonally oriented oblique muscles are involved in most leg is pulled posteriorly to lie behind the lower leg trunk rotation, lateral flexion, stabilization of the pelvis or to drape off the side of the table while ensuring that (which supports the spinal column) and (along with the patient does not roll posteriorly off the table. This transversus abdominis and rectus abdominis) com­ positioning places tension on the fibers of the oblique pression of the abdominal viscera. Compression of the abdominal muscles and 'opens up' the lateral abdominal viscera affects positioning of the organs so as to oppose area, which results in better palpation. the diaphragm's downward movement. When the dia­ phragm encounters the viscera and its central tendon Myofascial release (MFR) of the lateral abdomen can be is stabilized, the diaphragmatic attachments on the ribs used as preparation for further NMT techniques or as a pull the ribs into a 'bucket handle' movement, thereby (sometimes profoundly successful) treatment itself. MFR influencing lateral d imension of the thorax (which techniques are applied to the tissues before any lubrica­ ultimately influences anterior / posterior dimension tion is used as they are most effectively employed on dry (,pump handle'» and significantly affecting respiratory skin. They should be applied to each side of the body as mechanics (further discussion is found in Volume 1 , their effectiveness can be profound and may cause postural Chapter 14). imbalance if used unilaterally. When producing rotation of the trunk, the external To most easily apply a broad myofascial release to the oblique is synergistic with the contralateral internal lateral abdominal muscles, the practitioner stands oblique. However, when performing sideflexion, it is posterior to and just above the waist of the sidelying synergistic with the ipsilateral internal oblique (and patient and treats one side of the body at a time. The antagonistic to the contralateral one). This unique patient's uppermost arm is draped upward to lie on the situation well illustrates how a muscle can be both a side of his head while his uppermost leg is allowed to synergist and an antagonist to another muscle. hang posteriorly off the table, if comfortable and stable. The practitioner's arms are crossed so that the practi­ The more horizontally oriented transversus abdominis tioner 's caudal hand ( fingers wrapping anteriorly) is constricts the abdominal contents, thereby contributing placed on the patient's lower ribs and the cephalad hand to respiration by positioning the viscera as well as (fingers facing anteriorly) cups the uppermost edge of the preventing the subsequent anterior rotation of the pelvis iliac crest and anchors itself on this bony ridge. When (which abdominal distension would produce) with its applying pressure to engage the elastic components, only numerous postural consequences. Its attachment into the a small amount of pressure is oriented into the torso, just thoracolumbar fascia gives it potential to provide enough to keep the hands from sliding on the skin. The support for the lumbar region, as explained on p. 248. remaining pressure is applied in a horizontal direction to create tension on the tissues located between the two Trigger point patterns for lateral abdominal muscles are known to cross the mid-line into the contralateral side of the abdomen and to radiate up into the chest and to the

282 CLINICAL APPLICATION OF NMT VOLUM E 2 External oblique Belch button Fig. 1 0.47B Fig. 1 0.47A Lateral abdominals Causes diarrhea Fig. 1 0.48 Fig. 1 0.49 Figures 1 0.47, 1 0.48, 1 0.49 Trigger point patterns of lateral abdominal muscles. These patterns may include referrals which affect viscera and provoke viscera-like symptoms, including heartburn, vomiting, belching, diarrhea and testicular pain (adapted with permission from Simons et al ( 1 999). Fig. 49. 1 A-C).

THE LUMBAR SPINE 283 &--.••... . Figure 1 0.50 A broad application of myofascial release to the lateral Figu re 1 0.51 The tissues are secured by the thumb of one hand abdominal muscles. Stretch of the tissues can be augmented by while the fingers of the opposite hand provide a curling, penetrating placing the patient's arm and leg (draped off table posteriorly) as drag on the lateral abdominal muscles. shown, which produces mild traction on the tissues. hands. As the hands move away from each other, taking moved caudally and placed on the next segment. These up the slack in the tissues located between the two hands, steps are repeated in small segments until the iliac crest an elastic barrier will be felt and held under mild tension is reached. The practitioner's hands then return to the (Fig. 10.50). lower rib area and are moved anteriorly onto the next column of oblique tissues and the steps are repeated until This elastic barrier is held until the fascial tissues the lateral edge of rectus abdominis is encountered . elongate in response to the applied tension. After 90-120 seconds (less time if skin rolling has been applied first), The curling, dragging techniques can also be applied the first release of the tissues will be felt as the gel from an anterior/ posterior direction to all of the lateral changes to a more solute state. The practitioner can abdomen or transversely across the fibers. Taut fibers are follow the release into a new tissue barrier and again sometimes more palpable in one direction than the other. apply the sustained tension. The tissues usually become softer and more pliable with each 'release' ( Barnes 1 997). Friction can be applied to all rib attachments as well as the attachments onto the iliac crest. If attachments are too The lateral abdomen of the sidelying patient can now tender for friction techniques to be used, sustained be lightly lubricated for a more detailed examination of ischemic compression may result in satisfactory release of the tissues. Tissues affected by these steps will include the tissue. Trigger points often occur on or near the the external abdominal oblique, internal abdominal attachments and these portions of the muscle may be oblique and transversus abdominis. exquisitely tender. The first column of tissues to be addressed lies just Since there are no bony surfaces to compress the mid­ lateral to the quadratus lumborum. The horizontally fiber trigger points against, attempts can be made to pick placed thumb of one hand is used to secure the tissues up and compress or roll the oblique fibers between and to provide a tensional element while the fingers of thumb and fingers (Fig. 1 0.52). However, this may be the opposite hand provide a curling, penetrating drag on unsuccessful, particularly on the deeper fibers. Spray­ the tissues (Fig. 10.51). and-stretch teclmiques have been found by one author (JD) to be successful for reduction of trigger point The tissues are examined i n small segments which are patterns, as has briefly applied contrast hydrotherapy just inferior to the placed thumb. The fingers (nails well (alternating hot and cold applications for 1 0-20 seconds, trimmed) are placed just caudal to the thumb and provide repeated 1 0-1 2 times) followed by stretching of the tissues. a 3-4 inch gliding stroke which drags the fingers down Spray-and-stretch techniques are fully covered for these the tissues while the fingers simultaneously flex and curl. muscles by Simons et al (1 999, Chapter 49). This curling action causes penetration into the underlying tissues which is very different from (and more effective Rectus abdominis than) that provided by only dragging the fingers. Attachments: Costal cartilages of the 5th-7th ribs, xyphoid The curling, dragging technique is applied to this 'segment' 4-5 times before the thumb and fingers are

284 CLINICAL APPLICATION OF NMT VOLUME 2 Indications for treatment • Pain in the mid-posterior thorax, sacroiliac and lower back regions • Pain in the lower quadrant of the abdomen where, on the right side, McBurney's point can duplicate the / pain of appendicitis • Infant colic • Pain into the chest (not cardiac in origin) • Pain into the abdomen, thereby creating many of the visceral patterns discussed in Box 1 0. 1 0 • Loss of abdominal tone • Painful menses Figure 1 0.52 Attempts can be made to pick up and compress or roll Pyramidalis the oblique fibers between thumb and fingers. Attachments: From the anterior pubis and its symphysis process and the intervening ligaments to attach to the linea alba, midway between the symphysis and caudally to the pubic crest and symphysis pubis the umbilicus Innervation: Intercostal nerves (TS-12) Muscle type: Phasic (type 2) with tendency to inhibition, Innervation: 1 2th thoracic nerve weakening Muscle type: Phasic (type 2) with tendency to inhibition, Function: Flexes the thoracic and lumbar spine, supports and compresses the abdominal viscera, anterior support weakening of the spinal column by stabilization of pelvic position Function: Compresses the abdomen to support the (decreasing lordosis). Also assists in forced expiration, especially coughing viscera by tensing the linea alba Synergists: For flexion of spinal column: obliquus externus Synergists: Obliquus externus abdominis, obliquus abdominis, obliquus intenms abdominis and, depending upon spinal position, possibly psoas internus abdominis, transversus abdominis, rectus For compression and support of abdominal viscera: obliquus abdominis, quadratus lumborum and diaphragm externus abdominis, obliquus internus abdominis, Antagonists: Gravity transversus abdominis, pyramidalis, quadratus lumborum and diaphragm Indications for treatment For forced expira tion : obliquus externus abdominis, obliquus internus abdominis, transversus abdominis, Pain at lower abdomen close to mid-line in the region of internal intercostals (except parasternal internal the muscle. intercostals) and (with increased demand) the latissimus dorsi, serratus posterior inferior, quadratus Special notes lumborum and iliocostalis lumborum Antagonists: To flexion of spinal col u m n : paraspinal The vertically oriented fibers of rectus abdominis muscles primarily contribute to flexion of the thoracolumbar To compression and support of abdominal viscera: gravity spine (possibly some lateral flexion) and assist in To forced expiration: diaphragm, scalene, parasternal stabilizing the pelvis to avoid anterior tilt with its resultant significant postural consequences. The upper internal intercostals, levator costorum, upper and fibers can pull the upper body anterior to the coronal line lateral external intercostals and (with increased and help sustain a forward head position. The lower demand) the sternocleidomastoid, upper trapezius, fibers often show loss of tone and allow the pelvis to serratus anterior, serratus posterior inferior, pectoralis move into anterior tilt, thereby increasing lumbar lordosis major and minor, latissimus dorsi, erector spinae, and significantly influencing the spinal positioning in subclavius and omohyoid general. Rectus abdominis is divided by 3-4 (sometimes more or less) tendinous inscriptions which receive nerve supply from different levels, thereby allowing each section to act independently and to influence each other. Considering how this anatomy applies to trigger point formation theories (see p. 18 and Volume 1 , Chapter 6) one can readily see the great propensity for this muscle to

THE LUMBAR SPINE 285 form trigger points as each section lying between McBurney's point tendinous inscriptions may produce both central and attachment trigger points. Figure 1 0.54 Trigger points in rectus abdominis can duplicate pain symptoms of appendicitis (adapted with permission from Travell & At the mid-line, the rectus sheaths merge to form the Simons (1 992) ). linea alba. Separation of the rectus muscles (common after pregnancy) is noted as a palpable groove at the mid­ line, especially detectable when the person is asked to contract the muscles by performing a partial sit-up. Herniations of the linea alba may be palpable only when the patient is standing. With rectus abdominis imbalance, the umbilicus can be seen to deviate toward the stronger (hyperactive) side and away from the weak, inhibited muscle, especially during various movement activities (laughing, coughing, leg lifting, etc.) (Simons et al 1 999) and is usually apparent when the patient is asked to do a quarter sit-up with his arms crossed on his chest (Hoppenfeld 1 976) . This procedure i s used to test the integrity o f the spinal segment which innervates the rectus abdominis and the corresponding paraspinal muscles (which should also be assessed for weakness) and is considered a positive 'Beevor's sign' when the umbilicus deviates to one side. Trigger point patterns for the anterior abdominal muscles are into posterior mid-thoracic, sacroiliac and lower back regions, into the lower quadrant of the abdo­ men (into McBurney's point on right side, duplicating the pain of appendicitis), into the chest and into the abdo­ men, thereby creating many of the visceral patterns pre­ viously discussed, including dysmenorrhea, pseudocardiac pain and colic (Figs 1 0.53-55). TrPs from rectus �� -I--\\':;;; ; �� abdominis muscles upper attachment ;\\-.-l --- I- Lower attachment Figure 1 0.53 Trigger points in rectus abdominis can refer posteriorly y into the back (adapted with permission from Travell & Simons ( 1 992) ). Dysmenorrhea Figure 1 0.55 Painful or difficult menstruation (dysmenorrhea) may be due to rectus abdominis trigger points (adapted from Simons et al ( 1 999), Fig. 49.2 A-C).

286 CLINICAL APPLICATION OF NMT VOLUME 2 Stretching and strengthening of the abdominal muscles are indicated in many respiratory and postural dysfunc­ tions as these muscles are often significantly involved. Lack of tone in these muscles may contribute to lower back problems, as has been d iscussed within this chapter. Rehabilitation and strengthening of these muscles are important to spinal stability and details are offered in Chapter 7 of a self-applied abdominal muscle rehabilitation. NMT for anterior abdominal wall Figure 1 0.56 The pads of several fingers or the heel of the hand can mu scles be used to broadly apply sustained ischemic compression for a general release of the upper rectus abdominis. The practitioner uses lightly lubricated gliding strokes or finger friction on the anterior and lateral aspects of the reaching across the body to treat the contralateral side inferior borders and external surfaces of the 5th through while stroking the fingers toward the mid-line. 1 2th ribs to search for taut fiber attachments and tender areas where many of the abdominal muscles fibers As the distal end of the rectus abdominis is attach. Caution is exercised regarding the often sharp tips approached, the patient should be informed about the of the last two ribs, which are usually more posteriorly attachment site onto the pubic crest and why the prac­ placed but may (rarely) wrap around anteriorly. titioner is approaching this area. The male patient should be asked to displace the genitals toward the non-treated Palpation of the upper 2 or 3 inches of the rectus side and to 'protect' the area while the practitioner abdominis fibers which lie over the abdominal viscera palpates the upper aspect of the pubis and frictions the may reveal tenderness associated with trigger points or rectus abdominis attachments (Fig. 1 0.57). Whether the with postural distortions, such as forward slumping pos­ tures, which overapproximate these fibers and shorten Figure 1 0.57 The patient can be asked to 'protect' the area while the them. Extreme tenderness in these tissues or tenderness practitioner palpates the upper aspect of the pubis and frictions the which returns rather quickly after treatment may also be rectus abdominis attachments. associated with underlying visceral conditions and caution should be exercised until visceral involvement of liver, gallbladder, stomach, etc. has been ruled out. If not contraindicated by visceral involvement, the pads of several fingers or the heel of the hand can be used to broadly apply sustained ischemic compression for a general release of the upper rectus abdominis (Fig. 1 0.56). A more precise application of sustained pressure can be placed on any taut bands found after this more general technique has been used. The fibers of rectus abdominis may be further softened with short effleurage strokes in the same manner as described previously for the oblique muscles. The curling, dragging techniques, applied both vertically and trans­ versely to the lightly lubricated rectus abdominis area, may reveal tender areas and specific fiber bands worthy of more attention. (See hand positioning and treatment steps with the lateral abdomen descriptions.) A separated linea alba may be felt in the direct center of the upper rectus abdominis and will be palpated as a lack of resistance where the tissue has split apart. Having the person curl up slightly to tense the rectus abdominis may produce a more profound palpation of the split. This area of weakness should be treated with caution (especially with transverse applications) and the tissues involved should be stroked toward the mid-line rather than away from it. This is easily accomplished by

THE LUMBAR SPINE 287 patient is male or female, it is advisable to have a second Figure 1 0.58 Discomfort in the most lateral fibers of rectus person iri. the room as a chaperone since both the prac­ abdominis can be misleading as they lie directly over the psoas titioner and the patient are vulnerable when treating near muscle and can be provoked when palpating for psoas. the pubic area. The pyramidalis muscle will also be treated during the final segment of the lower rectus abdominis as it merges into the linea alba midway between the umbilicus and its attachment on the pubic crest. Specifically applied gliding strokes or transverse friction can be appropriately used . The most lateral aspect of the rectus abdominis should be examined due to its high propensity for trigger point formation. Additionally, it lies directly over the psoas muscle and discomfort in these lateral fibers of rectus abdominis during palpation of the psoas can be mis­ leading. The practitioner 's thumbs, oriented tip to tip with the pads placed on the lateral aspect of the most lateral fibers of rectus abdominis, can be used to press into, probe and treat the fibers with sustained com­ pression or transverse snapping strokes (if not too tender) (Fig. 1 0.58). Asking the patient to curl into a quarter sit-up will assist in locating the muscle's edge but the muscle should be relaxed when palpated. Box 1 0. 1 1 Lief's abdomi nal NMT protocol Figure 1 0.59 Neuromuscular abdominal technique. Suggested l ines of application to access primary trigger point attachment sites Lief's NMT treatment of the abdominal and related areas focuses and interfaces between different muscle groups (reproduced with largely on specific junctional tissues: permission from Chaitow (1 996) ). • central tendon and the lateral aspect of the rectus muscle sheaths • thoracic attachments of the rectus abdominis and external oblique muscles • xiphisternal ligament • lower attachments of the internal and external oblique muscles • intercostal areas from 5th to 1 2th ribs. Lief's abdominal NMT application (Fig. 1 0.59) In treating the abdominal and lower thoracic regions the patient should be supine with the head supported by a medium-sized pillow and the knees flexed, either with a bolster under them or drawn right up so that the feet approximate the buttocks. Lubricant should be applied to the area being treated. Intercostal treatment The practitioner is positioned level with the patient's waist and a series of strokes are applied with the tip of the thumb, or with a finger tip, along the course of the intercostal spaces from the sternum, laterally (see descriptions of Lief's thumb and finger techniques in Volume 1 , Chapter 9). It is important that the insertions of the internal and external intercostal muscles receive attention. The margins of the ribs, both inferior and superior aspects, should receive firm gliding pressure from the distal phalanx of the thumb or middle or index finger. If there is too little space to allow such a degree of differentiated pressure then a simple stroke along the available intercostal space should be made. If the thumb cannot be insinuated between the ribs, a finger (side of finger) contact can be used in which the gliding stroke is (continued overleaf)

288 CLINICAL APPLICATION OF NMT VOLUME 2 Box 1 0.1 1 Lief's abdominal NMT protocol (cont'd) drawn toward the practitioner (toward mid-line) from the In treating the ipsilateral side, it may be more comfortable to contralateral side. apply the therapeutic stroke via the flexed finger tips which are drawn toward the practitioner, or a thumb stroke may be used. In The intercostals from the 5th rib to the costal margin should treating the contralateral side, thumb pressure can more easily be receive a series of two or three deep, slow-moving, gliding strokes applied, as in spinal technique, with the fingers acting as a fulcrum on each side, with special reference to points of particular and the thumb gliding toward them in a series of 2 or 3 inch-long congestion or sensitivity. These areas may benefit from up to strokes. The sensing of contracted, gangliform areas of dysfunction 30 seconds of firm but not heavy, sustained or variable pressure is more difficult in abdominal work and requires great sensitivity of techniques. touch and concentration on the part of the practitioner. The practitioner should bear in mind the various reflex patterns Umbilicus in the region. Gentle searching of tissues overlying or surrounding the sternum may elicit sensitivity in the rudimentary sternalis A series of strokes should then be applied around the umbilicus. muscle which has been found to house trigger points. It is not Using thumb or flexed finger tips, a number of movements of a necessary for the practitioner to change sides during the treatment stretching nature should be performed in which the non-treating of the intercostals unless it is found to be more comfortable to do hand stabilizes the tissue at the start of the stroke which firstly runs so. from approximately 1 inch (2.5 cm) superior and lateral to the umbilicus on the right side, to the same level on the left side. The The practitioner should be facing the patient and be half-turned non-treating hand then stabilizes the tissues at this endpoint of the toward the head with her feet spread apart for an even distribution stroke and a further stretching and probing stroke is applied of weight and with her knees flexed to facilitate the transfer of inferiorly to a point about 1 inch (2.5 cm) inferior and lateral to the pressure through the arms. Most of the maneuvers in the umbilicus on the left side. This area is then stabilized and the intercostal area and on the abdomen itself involve finger and thumb stroke is applied to a similar point on the right. movements of a lighter nature than those applied to the heavy spinal musculature. The 'square' is completed by a further stroke upward to end at the point at which the series began. This series of movements Having assessed and, if appropriate, treated the intercostal should have a rhythmical pattern so that as the treating hand musculature and connective tissue (including trigger point reaches the end of its stroke, the non-treating hand comes to that deactivation, if necessary), the practitioner, using either a deep point and replaces the contact as a stabilizing pressure while the thumb pressure or a contact with the pads of the finger tips, treating hand begins its next movement. A series of three or four applies a series of short searching and treating strokes in a such circuits of the umbilicus is performed. combination of oblique lateral and inferior directions from the xyphoid process (see Fig. 1 0.59). Linea alba Lief's NMT of the rectus sheath Additional strokes should be applied along the mid-line, on the linea alba itself, while searching for evidence of contractions, Next, a series of deep slow strokes is applied along and under the adhesions, fibrotic nodules, edema and sensitivity. costal margins. The costal margin itself, as well as the tissues internal and cephalad to it, require diligent assessment as this is a CAUTION: Caution is always required to avoid deep pressure on key attachment location. Whether diaphragmatic attachments can the linea alba, especially if this muscular interface is weakened by be located is questionable but sustained, firm (but not invasively pregnancy, surgery or trauma. It should also be recalled that the aggressive) pressure allows gradual access to an area which can linea alba is a place of attachment of the external obliques as well reveal trigger points of exquisite sensitivity with virtually as transversus abdominis (Braggins 2000). unpredictable areas of influence. Many seem to produce sensations internally, while others create sensations in the lower European (Lief's) NMT for iliac fossa and symphysis extremities or in the throat, upper chest and shoulders. pubis Deactivation of such triggers needs to be carried out slowly, carefully and with sensitivity. The sheaths of the rectus abdominis muscles (Fig. 1 0.60), from the costal margins downwards to the pubic bones, are evaluated by A series of short strokes ( 1 -2 inches, 2.5-5 cm) with fairly deep finger or thumb strokes. Attention is given to the soft tissue but not painful pressure is then applied by the thumb, from the component as well as the insertions into the iliac fossa, the pubic mid-line out to the lateral aspect of the rectus sheath. This series of bones and the symphysis pubis, including the inguinal ligament strokes starts just inferior to the xyphoid and the last lateral stroke (see Fig. 1 0.59). concludes at the pubic promontory. This series may be repeated on each side several times depending upon the degree of tension, Strokes should be made, commencing at the ASIS, which congestion and sensitivity noted. attempt to evaluate those attachments of internal and external obliques and transversus abdominis which can be contacted. A similar pattern of treatment is followed across the lateral border of the rectus sheath. A series of short, deep, slow-moving, A deep but not painful stroke, employing the pad of the thumb, laterally oriented thumb strokes is applied from just inferior to the should be applied to the superior aspect of the pubic crest. This costal margin of the rectus sheath until the inguinal ligament is stroke should start at the symphysis pubis and move laterally, first reached. Both sides are assessed and treated in this way. in one direction and, after repeating it once or twice, then the other direction. A similar series, starting at the center and moving A series of similar strokes is then applied first on one side and laterally, should then be applied over the anterior aspect of the then the other, laterally from the lateral border of the rectus sheath pubic bone. Great care should be taken not to use undue pressure and onto the oblique abdominal muscles. These strokes follow the as the area is sensitive at the best of times and may be acutely so contour of the trunk so that the more proximal strokes travel in a if there is dysfunction associated with the insertions into these slightly inferior curve while passing laterally, while the more distal structures. A series of deep slow movements is then performed, via strokes have a superior inclination which follows the iliac crest, as the thumb, along the superior and inferior aspects of the inguinal the hand passes laterally. A total of five or six strokes should ligament, starting at the pubic bone and running up to the iliac complete these movements and this could be repeated before performing the same movements on the contralateral side. crest. (continued overleaf)

THE LUMBAR SPINE 289 Box 1 0. 1 1 Lief's abdominal NMT protocol (cont'd) Rectus ---.¥\\\"1 External Transverse abdominis oblique abdominis Internal --\"-£\"/ oblique p�--¥ Inguinal �'\"9\"ioal ligam,\"1 ligament AB C Conjoint tendon Figure 1 0.60 A: Rectus abdominis. B: Right internal and left external obliques. C: Left transversus abdominis (adapted from Braggins (2000) with permission). In this lower abdominal area, close to the ASIS and toward the lateral rectus abdominis border at its lower margins and deep umbilicus, many of the tender points associated with flexion strains pressure applied toward the mid-line. The hand or thumb should of the lumbar and lower thoracic spine may be located. Positional then slowly move cephalad in short stages while maintaining this release methods should be employed to relieve the dysfunctional medial pressure. This lifts the connective tissue from its underlying patterns associated with these (see Volume 1 , Chapter 1 0, as well attachments and helps to normalize localized contractures and as specific discussion of PRT in this chapter on p. 290 relating to fibrous infiltrations. the abdominal musculature). A soothing series of massage strokes should complete attention The thumbs or finger tips may then be insinuated beneath the to this vital and sensitive region. MET for abdominal muscles postural and phasic fiber types and that it is the mix, the ratio, of type 1 and type 2 fibers, as well as the function of Local the muscle, that determines whether it is classified as phasic or postural, and so whether its tendency is toward The abdominal muscles are phasic (using Janda's weakness/lengthening or tightness/ shortening when nomenclature - see Volume 1 , Chapter 2) and therefore 'stressed'. This means that a phasic muscle contains do not shorten as a whole when stressed, but rather display postural fibers which are likely to shorten under adverse evidence of inhibition and lengthening. This contributes conditions (overuse, misuse, disuse, etc.), just as the to instability in the spinal structures, as discussed earlier phasic fibers in a postural muscle may weaken and in this chapter. However, all abdominal muscles are lengthen under similar conditions. capable of developing trigger points and areas of localized shortening, fibrosis, adhesions, etc. which may require When treating local dysfunctional changes, tactics might normalization if contributing to pain or dysfunction. usefully include initial use of an isometric contraction followed by local stretching involving 'e' or '5' bends, If there is confusion as to why a 'weakened' or local myofascial release or other deactivating and inhibited phasic muscle should require stretching, it may lengthening techniques as presented in this text (such as be useful to reread Volume 1, Chapter 2. The discussion those previously discussed for paraspinal use in the in that chapter explains that all muscles have both multifidi section).

290 CLINICAL APPLICATION OF NMT VOLUM E 2 Global abdominal MET The use of SEIS involves the slow stretching of a muscle, or group of muscles, while they are contracting or are attempting to maintain a shortened, contracted state (see p. 270 for description of this isotonic eccentric method in treatment of the erector spinae). This method effectively tones the inhibited antagonists to the short, tight, postural musculature. By slowly stretching the abdominal muscles while they are holding a flexed position, the abdominal muscles will be toned and the erector spinae released from excessive tone (Liebenson 2001). The mechanisms whereby strength and tone are restored to the abdominal muscles, following this type of procedure, involve a combination of active exercise (resisted isotonic contraction) and release of previously tight erector spinae musculature through reciprocal inhibition. PRT for abdominal muscles Figure 1 0.61 Position of ease for flexion strain of T9 to lower lumbar regions involving flexion, sidebending and rotation until ease is • Tender points (which may or may not also be trigger achieved in a monitored tender point on the lower abdominal wall or points) located in the abdominal musculature often the ASIS area (adapted from Chaitow ( 1 996b ) ) . represent dysfunction of the lumbothoracic region resulting from strain or stress which occurred in flexion. Deep abdominal muscles (Fig. 1 0.62) For a greater understanding of the strain-counterstrain concepts which support this assertion, see Volume 1 , The muscles of the deep abdomen include the psoas major, Chapter 1 0 (or Chaitow 1 996b, Deig 2001 o r Jones 1 981 ). psoas minor and quadratus lumborum. These muscles are also referred to as the lateral trunk muscles • Gross positioning to relieve lumbar flexion stresses (Hoppenfeld 1 976) and as the deep muscles of the and strains takes the patient painlessly into flexion (Fig. abdominal wall (Platzer 1992). While the psoas is dis­ 1 0.61 ), with the final position of ease being held for at cussed at length here, the quadratus lumborum has been least 90 seconds. presented with the posterior lower back muscles since it was treated in a prone position (see p. 258). • The position of ease is determined by means of palpation of the tender point, with the patient reporting The companion muscle to the psoas, the iliacus, is on the change in 'score' as the positioning is fine tuned. considered in this text with the treatment of the pelvis in Chapter 11 (p. 348) due to its extensive pelvic attachments • A score of 3 or less is the objective, having and the tremendous influence it has on pelvic positioning. commenced from a score of 10 before the repositioning Both iliacus and psoas are hip flexors and so are also starts. discussed in Chapter 12 (p. 410) with the hip region. • Jones (1981 ) reports that Ll has two tender points: Psoas major one is at the tip of the anterior superior iliac spine and the other on the medial surface of the ilium just medial to Attachments: From the lateral borders of vertebral ASIS. bodies, their intervertebral discs of T1 2-L5 and the transverse processes of the lumbar vertebrae to attach • The tender point for 2nd lumbar anterior strain is (with iliacus) to the lesser trochanter of the femur found lateral to the anterior inferior iliac spine. • The tender point for L3 lies an inch (2.5 cm) below a line connecting Ll and L2 points. • L4 tender point is found at the attachment of the inguinal ligament on the ilium. • L5 points are on the body of the pubis, just to the side of the symphysis. • In bilateral strains both sides should be treated. L3 and L4 usually require greater sidebending in fine tuning than the other lumbar points.

THE LUMBAR SPINE 291 ---�!i=Inferior vena cava (cut) Right leaf of central ...�. '='>�_ ---_+._--'--' --- Oesophagus (cut) tendon of diaphragm ---:\"tf'= -+--\"+' Left leaf of central tendon of diaphragm _----\"-,: *\"\"\"\"\" ,.,\".\".-,,- .#.;, ----- Median arcuate ligament Aorta (cut) ----�H_-_ -t+-:�_+'__+l_ , Lateral and medial +..-F...�. ��'-.-' .--- -- Left crus of diaphragm arcuate ligaments Right crus of diaphragm --_-7f+;'�\" --+-'-- Quadratus lumborum -'-';-\"i: Psoas minor --'-_--\"--''-:'-'---' -_L- _ Psoas major ' 8,:\";':-';-:7; Iliacus 7-'-'-- Anterior superior iliac spine I\"'-:=�-_,:*'\"� Inguinal ligament Piriformis ;';:�;.Loa.,�, =Hf�:\":;\":;' 7--- Coccygeus Levator ani ----=:-'! -!.'.�E.:;!l_-_?\"�; \"\"=\"' __=� --:-::: \"2:\":-:�-'-;�-; ,.£1�; -'7:'-:'-:':-- Pubic tubercle Pectineus Tensor fasciae latae �\\::-.7=:'\\\"�; Adductor longus -:-+�i!=-:,.;�'E! G racilis =-;�£-=C-�;f: Sartorius �-':':\"�!-7: Rectus femoris �t=:1,=='-\"H;:�, Adductor magnus '-'-=;--' Vastus lateralis r-'�td!---H.-:'7 f:7:': !--'--- Vastus medialis ..,-. Iliotibial tract Figure 1 0.62 Psoas major and minor as well as quadratus lumborum comprise the deep abdominal muscles. Portions of piriformis, coccygeus and I!wator ani are also shown here and are discussed with the pelvis in Chapter 1 1 (reproduced with permission from Gray's anatomy (1 995) ). Innervation: Lumbar plexus (U-3) extends the lumbar spine when standing with normal Muscle type: Postural (type I ), prone to shortening under lordosis, (perhaps) flexes the spine when the person is bending forward, compression of the lumbar vertebral stress column, questionable as to whether it can rotate, Function: Flexion of the thigh at the hip, (minimal) lateral sidebend or otherwise move the spine (Bogduk 1 997) rotation of the thigh, (minimal) abduction of the thigh,

292 CLINICAL APPLICATION OF NMT VOLUM E 2 Synergists: For hip flexion : iliacus, rectus femoris, Special notes pectineus, adductors brevis, longus and magnus, sartorius, gracilis, tensor fascia latae The bilateral psoas major bellies, subdivided into super­ For lateral rota tion of the th igh: long head of biceps ficial and deep portions, descend the anterior aspect of femoris, the deep six hip rotators, gluteus maximus, the lumbar spine to join with the iliacus muscle as they sartorius, posterior fibers of gluteus medius and both (surrounded by iliac fascia) course through the minimus, and iliacus lacuna musculorum (deep to the inguinal ligament) to For abduction of the thigh: gluteus medius, minimus and attach to the lesser trochanter of the femur. Two bursae, part of maximus, tensor fascia latae, sartorius, the iliopectineal bursa and the iliac subtendinous bursa, piriformis and iliacus lie between the muscle (or its tendon) and the underlying For extension of the spine: paraspinal muscles bony surfaces. For flexion of the spine: rectus abdominis, obliquus externus abdominis, obliquus internus abdominis, The psoas major may also communicate with: transversus abdominis • fibers of the diaphragm, psoas minor, iliacus, Antagonists: To hip flexion : gluteus maximus, the ham­ quadratus lumborum and pectineus string group and adductor magnus To lateral rotation of the thigh : semitendinosus, semi­ • the posterior extremity of the plural sac membranosus, tensor fascia latae, pectineus, the most • the medial arcuate ligament anterior fibers of gluteus minimus and medius and • extraperitoneal tissue and peritoneum (perhaps) adductor longus and magnus • kidney and its ureter To abduction of the thigh : adductors brevis, longus and • renal, testicular or ovarian vessels magnus, pectineus and gracilis • the genitofemoral nerve, lumbar plexus and femoral To spinal extension: rectus abdominis, obliquus externus abdominis, obliquus internus abdominis, transversus nerve abdominis • the abdominal aorta, vena cava, external iliac artery To spinal flexion: paraspinal muscles and femoral artery and vein Psoas minor • the colon • the lumbar vertebrae and lumbar vessels Attachments: From T12 and the upper one or two lumbar • the sympathetic trunk vertebrae and the disc between them to the superior • and aortic lymph nodes. ramus of the pubis and iliopubic eminence via iliac fascia The sometimes present (50-60% according to Travell & Simons (1 992)) psoas minor courses anterior to the major Innervation: Lumbar plexus and ends at the pubic ridge with attachments also Muscle type: Postural (type I ), prone to shortening spanning to the iliac fascia. Since it does not cross the hip joint (and therefore cannot act upon it), it likely provides under stress weak trunk flexion (Gray's anatomy 1 995), extension of the Function: Assists in flexion of lumbar spine lordotic curve and elevation of the ipsilateral pelvis Synergists: Rectus abdominis, obliquus externus anteriorly (Travell & Simons 1 992). abdominis, obliquus internus abdominis, transversus At the lumbar attachments of psoas major, tendinous abdominis arches are formed on the lateral side of the vertebral Antagonists: Paraspinal muscles bodies and through these arches course the lumbar arteries, veins and filaments from the sympathetic trunk Indications for treatment of psoas muscles (Gray's anatomy 1 995). The lumbar plexus courses between the two layers of the psoas major and is vulnerable to • Low back pain neural entrapment; whether this is produced by taut • Pain in the front of the thigh bands of trigger points has yet to be established (Travell • Difficulty rising from seated position & Simons 1 992) . • Inability to perform a sit-up • Loss of full extension of the hip Controversy exists as to the extent of various functions • 'Pseudo-appendicitis' when appendix is normal of the psoas major but all sources agree that it (along with • Scoliosis iliacus) is a powerful flexor of the hip joint. EMG studies • Abnormal gaiting suggest that it laterally rotates the thigh, does not parti­ • Difficulty climbing stairs (where hip flexion must be cipate in medial rotation of the thigh, flexes the trunk for­ ward against resistance (as in coming to a sitting position significant) from a recumbent one) and that it is active in balancing the trunk while sitting (Gray's anatomy 1 995). Psoas major is the most important of all postural muscles

THE LUMBAR SPINE 293 (Basmajian 1 974). If it is hypertonic and the abdominals Figure 1 0.63 Referral pattern for iliopsoas may continue further than are weak, exercise is often prescribed to tone these weak illustrated into the sacrum and proximal medial buttocks. Additionally. it abdominaIs, such as curl-ups with the dorsum of the foot may refer into the upper anterior thigh (not illustrated) (adapted from stabilized. This can have a disastrously negative effect, Travell & Simons ( 1 992) ) . far from toning the abdominals, as increased tone of the already hypertonic psoas may result, due to the sequence medial buttocks (Fig. 1 0.63). Additionally, it may refer created by the dorsum of the foot being used as a point of into the upper anterior thigh (not illustrated). support. When this occurs (dorsiflexion), the gait cycle is mimicked and there is a sequence of activation of tibialis In unilateral psoas spasms, a primary mechanical anterior, rectus femoris and psoas. If, on the other hand, involvement is usually at the lumbodorsal junction, the feet could be plantarflexed during curl-up exercises, though a rotary stress is noted at the level of the 5th then the opposite chain is activated (triceps surae, lumbar. Attention to the muscular components should be hamstrings and gluteals), inhibiting psoas and allowing a primary focus, as attempts to trea t the resulting pain, toning of the abdominals. Additionally, full sit-ups activate which is frequently located in the region of the 5th lumbar the psoas when T12 leaves the ground . Curl-ups or pelvic and sacroiliac, by attention to the osseous element will be tilts are better designed for abdominal toning, with of little use (Chaitow 200 1 ) until the muscular tension is diagonal movements added to assist in toning the lateral reduced. abdominal wall, without placing undue stress on psoas. Bogduk et al (1 992) and Bogduk (1 997) provide The psoas major behaves in many ways as if it were an evidence that psoas plays only a small role in the action internal organ (Lewit 1 985). Tension in the psoas may be of the spine and that it 'uses the lumbar spine as a base secondary to kidney disease and may reproduce the pain from which to act on the hip'. Bogduk also notes: of gall bladder disease (often after the organ has been removed) . It has been noted that the psoas major Psoas potentially exerts massive compression loads on the communicates with fibers of the diaphragm as well as the lower lumbar disc. . .upon maximum contraction, in an activity the posterior extremity of the plural sac above (Gray's such as sit-ups, the two psoas muscles can be expected to exert anatomy 1 995) and Platzer (1 992) notes that: a compression on the LS-S1 disc equal to about 1 00 kg of weight. The fascia surrounds the psoas major as a tube, stretching from the medial lumbocostal arch to the thigh. Thus, any Liebenson (Chaitow 200 1 ) suggests that treatment aimed inflammatory processes in the thoracic regions can extend at relaxing a tight psoas and strengthening a weak gluteus within the fascial tube to appear as wandering abscesses as far maximus may be the ideal primary treatment for lumbo­ down as the thigh. sacral facet pain or paraspinal myofascial pain. Psoas fibers merge with (become 'consolidated' with) the Some visual evidence exists in determining psoas diaphragm and it therefore influences respiratory func­ involvement (Chaitow 2001 ). tion directly. Quadratus lumborum has a similar influence with the diaphragm. • Normal psoas function produces the abdomen 'falling back' rather than mounding when the standing Regarding spinal influences, Fryette ( 1954) maintains patient flexes. that the distortions produced in inflammation and /or spasm in the psoas are characteristic and cannot be pro­ duced by other dysfunction. He notes that when psoas spasm exists unilaterally, the patient is drawn forward and sidebent to the involved side with the ilium on that side rotating backwards on the sacrum and the thigh being everted . With bilateral psoas spasm, the patient is drawn forward, with the lumbar curve locked in flexion, thereby producing a characteristic reversed lumbar spine. The latter, if chronic, creates either a reversed lumbar curve if the erector spinae of the low back are weak or an increased lordosis if they are hypertonic. Lewit (1985) notes: 'Psoas spasm causes abdominal pain, flexion of the hip and typical antalgesic (stooped) posture. Problems in psoas can profoundly influence thoracolumbar stability' . Travell & Simons (1 992) note that trigger points in iliopsoas refer strongly to the lower back and may extend to include the sacrum and proximal

294 CLINICAL APPLICATION OF NMT VOLUME 2 • Similarly, if the supine patient flexes the knees and Figure 1 0.64 Test position for shortness of hip flexors. Note that the 'drags' the heels toward the buttocks (keeping them hip on the non-tested side must be fully flexed to produce full pelvic together), the abdomen should remain flat or 'fall back'. rotation. The position shown is normal (adapted from Chaitow (2001 ) ). If the abdomen bulges or the small of the back arches, thereby pulling the lumbar vertebrae into excessive • If effort is required to achieve 1 0° of hjp extension, lordosis, the psoas is suspect (Janda 1 983). this confirms iliopsoas shortening on that side. • If the supine patient raises both legs into the air and • If the thigh hangs down below a parallel (to the the belly mounds it shows that the recti and psoas are out floor) position without additional effort by the practi­ of balance. Psoas should be able to raise the legs to at tioner, it indicates a degree of laxity in iliopsoas. least 30° without any help from the abdominal muscles. • Further causes of failure of the thigh to rest parallel CAUTION: Kuchera (1997b) reports that: 'there are to the floor can be shortness of tensor fascia latae (TFL) or organic causes for psoas spasm that must be ruled out of rectus femoris (RF). If TFL is short (a further test by history, examination and tests, including: proves it: see Chapter 1 1 ) then there should be an obvious groove apparent at the iliotibial band on the lateral thigh • femoral bursitis and the patella, and sometimes the whole leg will deviate • arthritis of the hip laterally at the hip. If rectus femoris is suspected as the • diverticulosis of the colon cause of reduced range, the tested leg is held straight by • ureteral calculi [stones] the practitioner and the entire leg again lowered toward • prostatitis the floor for evaluation. If the thigh is now able to achieve • cancer of the descending or sigmoid colon 1 0° of hip extension, the responsible tissue is rectus femoris, • salpingitis.' whose tension on the hip joint was released when the knee (a joint it also crosses) was held in neutral. When treating, it is sometimes useful to assess changes in psoas length by periodic comparison of apparent arm • A further indication of a short psoas is if the prone length. The supine patient's arms are extended above the patient's hip is observed to remain in flexion or the lum­ head, palms together, so that the relationship of the finger bar region is pulled into excessive lordosis while either tips to each other can be compared. A shortness will com­ prone or supine. monly be observed in the arm on the side of the shortened psoas. This 'functional arm length differential' usually • The prone patient is asked to extend the straight leg normalizes a fter successful treatment. This method at the hip and if the movement commences with an provides an indication only of changes in psoas length anterior pelvic tilt, the psoas is assumed to have (or as confirmation of other findings, such as in the test shortened (Fig. 10.65). below) rather than a definitive diagnosis itself since there may be other reasons for apparent differences in arm Mitchell's psoas strength test length. • Before using MET methods to normalize a short Assessment of shortness in iliopsoas psoas, its strength should be evaluated, according to the developers of osteopathic muscle energy technique, (Fig. 10.64) Mitchell, Moran and Pruzzo (1 979). • Patient lies supine with buttocks (coccyx) as close to • They recommend that the supine patient should be the end of the table as possible and with the non-tested leg in full flexion at hip and knee, held there by the patient or by placing the sole of the non-tested foot against the lateral chest wall of the practitioner. Full flexion of the contralateral hip helps to maintain the pelvis in full posterior tilt with the lumbar spine flat, which is essential if the test is to be meaningful and stress on the spine avoided . • If the thigh of the tested leg fails to lie in a horizontal position in which it is (a) parallel to the floorI table and (b) capable of a movement into hip extension to approxi­ mately 1 0° without more than light pressure from the practitioner's hand, then the indication is that iliopsoas is short.

THE LUMBAR SPINE 295 Figure 1 0.66 A slowly rotating circular movement of the hands allows a steady, safe penetration deeply into the abdomen where psoas resides. Figure 1 0.65 A. Abnormal hip extension movement pattern is trimmed) are placed vertically at the lateral edge of rectus associated with shortened psoas. B. Leg raising is initiated with an abdominis approximately 2 inches lateral to the umbilicus anterior pelvic tilt. If excessive hamstring substitution occurs, the (Fig. 10.66). extended knee will flex (reproduced with permission from Chaitow (2001 ) ). • A steady, patient and painless pressure toward the spine is maintained with slight rotary movement of the placed at the end of the table, both legs hanging down fingers to insinuate the tips past any abdominal struc­ and feet turned in so that they can rest on the practi­ tures superficial to the anterior spine. If the aorta tioner 's lateral calf areas (practitioner stands facing the pulsation is strongly evident a slight deviation laterally patient at the foot of the table). should allow penetration of the finger tips until they sense contact with the psoas muscle (a fleshy or some­ • The patient should press firmly against the prac­ times very hard, not intestinal, resistance). titioner 's calves with his feet as she rests her hands on his thighs. • Once this contact has been made the patient is asked to slowly increase flexion of the hip. The elbow of the • The patient is asked to attempt to lift the practitioner practitioner's caudad arm is placed against the flexing from the floor. In this way the relative strength of one thigh to offer resistance which will cause the psoas to leg's effort as against the other can be assessed. contract firmly to confirm that the finger position is accurately placed. If the fingers lose contact with the • The practitioner judges which psoas is weaker or muscle fibers, the circular rotating approach is repeated stronger than the other. If a psoas has tested short (as in to help assure direct contact without intestinal entrap­ the test described above) and also tests strong in this test, ment (Fig. 1 0.67). then it is suitable for MET trea tment. • Once placement of the hands is confirmed to be • If, however, it tests short and also as weak, then directly on psoas, the practitioner uses her finger tips to other factors such as associated trigger points or tight apply a light direct compressive pressure onto the psoas. erector spinae muscles should be treated first, until psoas Fingers can be gently and slowly eased up or down the tests strong and short, at which time MET should be muscle (a couple of inches [2.5-5 cm] in each direction) as applied to start the lengthening process. well as pulled laterally across the muscle, ever staying mindful of the organ structures previously noted. When NMT for psoas major and minor tender areas or suspected trigger points are located, sustained pressure is applied for at least 8-12 seconds. Method 1 (working ipsilaterally) • Modifications can be made to the leg position by • Patient is supine, knees flexed with feet resting flat rotating the thigh medially (for the lateral aspect) and on the treatment table. The practitioner stands on the side laterally (for the medial aspect) . Add itionally, the to be treated at the level of the abdomen. patient's foot on the side being treated can be actively slid • The finger tips of the practitioner 's hands (nails well

296 CLINICAL APPLICATION OF NMT VOLUM E 2 /' Figure 1 0.67 Once psoas has been located, muscle testing is Figure 1 0.68 The iliopsoas tendon can be palpated between the applied by having the person actively flex the hip which presses the femoral artery and the upper fibers of sartorius. Caution should be knee against resistance applied by the practitioner's elbow. The exercised regarding the femoral artery by locating its pulse and contraction of psoas should be distinctly felt by the practitioner's finger avoiding further palpation to the region of the artery. The tendon is the tips to ensure correct hand placement. first myofascial tissue directly lateral to the femoral pulse. (by the patient) down the table slowly (returning the thigh to neutral position) to drag the psoas fibers under the compressing fingers for an active myofascial release. • The iliopsoas tendon is accessible just inferior to the inguinal ligament when the fingers are immediately lateral to the femoral pulse. With the leg (knee bent) resting against the practitioner, the inguinal ligament is located as well as the femoral pulse (see p. 353 for directions as to palpation of this region) . The practi­ tioner's first two fingers are placed between the femoral pulse and the sartorius muscle (Fig. 1 0.68). Static pressure is sustained or, if not too tender, gentle transverse friction is applied to the tendon of the psoas muscle, which may be exceptionally tender. Method 2 (working contralaterally) Figu re 1 0.69 Direct NMT treatment of psoas working through the linea alba (adapted from Chaitow L ( 1 988) Soft tissue manipulation. An alternative approach is suggested for those whose Healing Arts Press). knowledge of anatomy and pathophysiology is adequate to the recognition of the inherent risks involved in • The patient is positioned as in method 1 . applying direct pressure, through the mid-line, toward • The practitioner stands on the contralateral side and the lumbar spinal attachments of psoas (Fig. 1 0.69). reaches across the body to treat the affected side. • The fingers of the practitioner's cephalad hand are CAUTION: There is a very real risk attached to the placed vertically on the mid-line (linea alba) approxi­ application of pressure into the tissues of an aneurysm mately 1 .5 inches (4 cm) below the umbilicus. The fingers which may lie in the major blood vessels of this region use the same circular motion described above. and it is strongly suggested that this method only be used if there are no signs or symptoms of such a con­ dition and if contact with all obviously pulsating structures is avoided.

THE LUMBAR SPINE 297 • If the aorta pulsation is strongly evident a slight deviation laterally, one way or the other, should allow penetration of the finger tips until they sense a bony contact, the anterior surface of the lumbar spine. • Once this contact has been made, the fingers are slid away from the practitioner, around the curve of the lumbar vertebral body where a psoas contraction will be noted if the patient's flexed knee is brought cephalad against resistance from the practitioner's caudad hand (muscle test described in method 1 ) . • All other elements described i n method 1 are used to treat the muscle, which combines elements of ischemic compression, muscle energy technique and facilitated myofascial release. • The entire procedure is repeated to the second side if both psoas muscles require this form of slow release. MET treatment of psoas Figure 1 0.70 MET treatment of psoas in prone position with stabilizing contact on ischial tuberosity, as described by Greenman Method 1 ( 1 996) (adapted from Chaitow (200 1 ) ) . • The patient is prone with a pillow under the bring the thigh toward the table against resistance, using abdomen to reduce the lumbar curve. 1 5-25% of his maximal voluntary contraction potential, for 7-10 seconds. • The practitioner stands on the contralateral side, with the caudad hand supporting the thigh. • Following release of the effort (with appropriate breathing assistance, if warranted) the thigh is eased (if • The cephalad hand is placed so that the heel of that acute) to its new barrier or (if chronic) past that barrier hand is on the sacrum and applies pressure toward the and into patient-assisted stretch ('Gently push your foot floor to maintain pelvic stability. The fingers of that hand toward the ceiling'). are placed so that the middle, ring and small fingers are on one side of L2-3 segment and the index finger on • In chronic situations where the stretch is introduced, the other side (while the heel of the hand remains on the this is held for at least 20 seconds and ideally up to sacrum). This hand position allows these fingers to sense 30 seconds. a forward (anteriorly directed) 'tug' of the vertebrae, when psoas is moved past its barrier. • It is important that as stretch is introduced no hyper­ extension of the lumbar spine occurs. Pressure from the • An alternative hand position is offered by Greenman heel of hand on the sacrum or ischial tuberosity can (1996) who suggests that the stabilizing contact on the usually ensure that spinal stability is maintained. pelvis should apply pressure toward the table, on the ischial tuberosity, as thigh extension is introduced. • The process is then repeated on the same side before The authors agree that this is a more comfortable contact the other side is evaluated and treated if necessary. than the sacrum. However, it does not allow access to palpation of the lumbar spine during the procedure (Fig. Method 2 (Fig. 1 0.71 ) 1 0.70) . • This method involves using the supine test position • The practitioner eases the thigh (knee flexed) off the (as on p. 294), in which the patient lies with the buttocks table surface and senses for ease of movement into at the very end of the table, non-treated leg fully flexed at extension of the hip. If there is a strong sense of resistance hip and knee and either held in that state by the patient there should be an almost simultaneous awareness of the or by placement of the patient's foot against the prac­ palpated vertebral segment moving anteriorly when this titioner's lateral chest wall. resistance is due to psoas. • The practitioner stands at the foot of the table facing • If psoas is normal, it should be possible to achieve the patient with both hands holding the thigh of the approximately 10° of hip extension (without force) before extended leg. that barrier is reached. Greenman ( 1996) suggests: 'Normally the knee can be lifted 6 inches [15 cm] off the table. If less, tightness and shortness of psoas is present'. • Having identified the barrier, the patient is asked to

298 CLINICAL APPLICATION OF NMT VOLUM E 2 small degree of effort to externally rotate the leg and, at the same time, to flex the hip. • The practitioner resists both efforts and an isometric contraction of the psoas and associated muscles therefore takes place. • This combination of forces focuses the contraction effort into psoas very precisely. • After a 7-1 0 second isometric contraction and complete relaxation of effort, the thigh should, on an exhalation, either be taken (if acute) to the new restriction barrier without force or (if chronic) through that barrier, by applying slight painless pressure onto the anterior aspect of the thigh and toward the floor to stretch psoas. Either stretch position is held there for 30 seconds. • These steps are repeated until no further gain is achieved. Figure 1 0.71 MET treatment of psoas using G rieve's method PRT for psoas (Fig. 10.72) (adapted from Chaitow (2001 ) ). • The tender point for psoas is usually located at the • The leg on the affected side is placed so that the level of the inguinal ligament, where psoas crosses the medioplantar aspect of the foot rests on the practitioner's pubic bone. knee or shin. • The practitioner stands on the affected side at the • The practitioner's leg which supports the affected patient's thigh level and with the cephalad hand palpates side foot should be flexed slightly at the knee and hip, so for the tender point, creating discomfort which the that the patient's foot can rest as described. This places supine patient registers as '10' . the hip flexors, induding psoas, into a slightly mid-range position, not at their barrier. • The practitioner slowly brings the ipsilateral leg into flexion at the knee and hip and externally (usually, but • The practitioner should request the patient to use a sometimes internally if this reduces sensitivity more) rotates the hip, until a reported score of '3' or less is achieved. • This position is held for at least 90 seconds before a slow return to neutral is carried out. Figure 1 0.72 Positional release of psoas using tender point monitor on the pubic bone (adapted from Deig (200 1 ) ).

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300 CLINICAL APPLICATION OF NMT VOLUME 2 menopause: the breakthrough book on natural progesterone. Warner guidelines for doctors, 2nd edn. Royal College of Radiologists, Books, New York London Ranger 1 1971 Abdominal wall pain due to nerve entrapment. Levine J, Fields H, Basbaum A 1 993 Peptides and the primary afferent Practitioner 206:791 -792 Rantanan J, Hyrme M, Falck B 1 993 The multifidus muscle five years nociceptor. Journal of Neuroscience 1 3: 2273-2286 after surgery for lumbar disc herniation. Spine 1 9 : 1 963-1967 Lewit K 1 985 Manipulative therapy in rehabilitation of the locomotor Rasch P, Burke R 1 978 Kinesiology and applied anatomy. Lea and Febiger, Philadelphia system. Butterworths, London Richardson C 2000 Response from Carolyn Richardson. In: Bullock­ Lewit K 1992 Manipulative therapy in rehabilitation of the locomotor Saxton J, Murphy 0, Norris C, Richardson C, Tunnell P 2000 The muscle designation debate. Journal of Bodywork and Movement system, 2nd edn. 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Williams and Wilkins, Baltimore Clinical Biomechanics 10:323-324 Slocumb J 1 984 Neurological factors in chronic pelvic pain: trigger McGill S 1 991 Electromyographic activity of the abdominal and low points and the abdominal pelvic pain syndrome. American Journal back musculature during generation of isometric and dynamic axial of Obstetrics and Gynecology 1 49:536 trunk torque. Journal of Orthopedic Research 9:91 Snijders C, Vleeming A, Stoeckart R, Mens J, Kleinrensink G 1 997 McGill S 1 998 Low back exercises prescription for the healthy back. In: Biomechanics of the interface between spine and pelvis in different Resources manual for guidelines for exercise testing and positions. In: Vleeming A, Mooney V, Dorman T, Snijders C, prescri ption, 3rd edn. American College of Sports Medicine, Stoeckart R (eds) Movement, stability and low back pain. Churchill Williams and Wilkins, Baltimore Livingstone, Edinburgh McGill S, Norman R 1 993 Low back biomechanics in industry. 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CHAPTER CONTENTS Different pelvic types 301 MET of anterior innominate tilt: The pelvis Pelvic architecture 302 supine position 341 The pelvis (literally 'basin') 'is massive because its primary The pelvic girdle or ring 302 MET of posterior innominate tilt: function is to withstand compression and other forces Pregnancy and the pelvis 303 prone position 342 The innominates 306 due to body weight and powerful musculature___' (Gray's The symphysis pubis 307 Supine functional sacroiliac anatomy 1 995)_ The sacrum 307 assessments 343 The coccyx 310 Functional adaptations create the structural features of Ligaments of the pelvis 312 Prone pelvic assessment and SI the pelvis, which has locomotion and support as primary The sciatic foramina 313 treatment protocols 343 purposes in both genders and, in the female specifically, The sarcoiliac joint 314 Pelvic landmark observation and includes parturition_ The pelvis of the male and the female Gait and the pelvis 316 palpation 343 are, therefore, distinctly different and provide marked Therapeutic considerations 317 Mobility of the sacrum assessment skeletal variations_ Homeostatic subtext 318 in prone 343 Pelvic problems and the low Prone active straight leg raising A partial list of pelvic differences related to gender back 318 test 344 includes the following_ Lower crossed syndrome 318 Prone SI joint gapping test (and • The pelvic cavity is longer and more cone shaped in the Treatment sequencing 319 MET treatment) 344 Recognizing inappropriate firing MET for SI joint dysfunction 344 male and shorter and more cylindrical in the female_ Sacroiliac mobilization using • The male pelvis has a heavier architecture for sequences 320 MET 345 Possible trigger point Prone sacral PRT for pelvic attachment of larger muscle groups. (including SI joint) • The male iliac crest is more rugged and more involvement 321 dysfunction 346 Screening 321 Sacral foramen tender points 346 medially inclined anteriorly. The female ilia are more Mobilization with movement vertically inclined, but do not ascend as far as in the Janda's functional tests 321 (MWM) treatment of SI joint male, making the iliac fossae shallower. This Prone hip extension test 322 dysfunction 348 probably accounts for the greater prominence of the Hip abduction test 322 Tests for weakness 323 Muscles of the pelvis 348 hips in females (Gray's anatomy 1 995, p. 674). Strength and stamina testing Iliacus 348 NMT for iliacus 349 • The female sacral base and sacrum as a whole are for gluteus maximus and Positional release for iliacus 350 broader than in the male. medius 323 Gracilis 351 Strength testing for Pectineus 351 • The male acetabulum is larger than in the female. piriformis 324 Adductor longus 351 • In females the pubis, which forms the anterior pelvic Pelvic tilts and inclinations 325 Adductor brevis 351 Testing and treating pelvic, Adductor magnus 351 wall, has a lower height than the male. sacral, iliac and sacroiliac NMT for adductor muscle dysfunctions 326 group 354 DIFFERENT PELVIC TYPES Thoughts on treatment MET treatment of shortness in strategies 327 short adductors of the Gray's anatomy ( 1 995) suggests that there are four major Hypermobility issues 327 thigh 356 lIiosacral or sacroiliac? 329 PRT for short adductors 357 classifications of pelvic types. Differences are greater at Static innominate positional Tensor fasciae latae 357 the inferior aperture than at the brim (crest). evaluation 330 Lewit's TFL palpation 358 Static sacral positional NMT for TFL: supine 359 • Anthropoid (males only): which is common in males evaluation 330 Supine MET treatment of Sacral torsions 331 shortened TFL 360 and has a typical deep, fairly narrow, pelvic bowl. Standing pelvic assessments 331 Positional release for TFL 361 Standing pelvic orientation Quadratus lumborum 361 • Android (common in both males and females): which evaluation ('tilt') 332 NMT for quadratus lumborum: Standing pelvic balance sidelying position 361 is an intermediate design, somewhere between the test 332 Gluteus maximus 363 anthropoid and gynaecoid_ Standing PSIS symmetry NMT for gluteus maximus: test 332 sidelying position 364 301 Standing flexion (iliosacral) Gluteus medius 365 test 332 Gluteus minimus 366 Standing iliosacral 'stork' or NMT for gluteal muscle group: Gillet test 333 sidelying 367 Standing hip extension test 333 Lief's European NMT for the Spinal behavior during flexion gluteal area 368 tests 333 MET self-care for gluteus Standing and seated spinal maximus 369 rotoscoliosis tests 334 Positional release for gluteus Seated pelvic assessments 334 medius 369 Seated flexion (sacroiliac) Piriformis 369 test 334 NMT for piriformis: sidelying 372 Supine pelvic assessments and Sidelying MET and compression treatment protocols 334 treatment of piriformis 373 Pelvic alignment in supine prior NMT examination of iliolumbar, to assessment 334 sacroiliac and sacrotuberous Supine shear dysfunction regions 374 assessment 335 Iliolumbar ligament region 374 MET of a superior innominate NMT for iliolumbar ligament shear 335 region 375 Pubic dysfunction Sacroiliac ligament region 376 assessment 335 NMT for sacral region 378 MET treatment of pubic Positional release for sacroiliac dysfunction 337 ligament 378 Positional release methods for Sacrotuberous ligament 379 pubic shear/inguinal Sacrotuberous ligament method: dysfunction (or suprapubic prone position 382 pain) 337 Positional release for Supine iliosacral dysfunction sacrotuberous ligament 384 evaluation 338 Other muscles of the pelvis 384 MET of iliac inflare 340 The muscles of the pelvic MET treatment of iliac diaphragm 384 outflare 340 NMT for intrarectal region 386 MET of anterior innominate tilt: prone position 341 Boxes are listed on page xvi and referenced in the index

302 CLIN ICAL APPLICATION OF NMT VOLUME 2 • Gyl1aecoid (females only): characterized by a wide and comprises the junction of the ilium, ischium and the pubic bones and its articulation with the femur consti­ shallow pelvic bowl. tutes a true ball and socket joint. • Platypelloid (rare): which has an even wider and The pelvic girdle or ring shallower pelvic bowl than the gynaecoid. This is formed from: PELVIC ARCHITECTURE • two innominate bones (literal meaning: 'nameless') which are formed from the ilia, ischia and pubic The pelvis is composed of two innominate bones (each bones. These three bones have cartilaginous made up of an ilium, ischium and pubis), with the connections which fuse to become one bone by adult sacrum wedged between the ilia posteriorly. The ilium, life ischium and pubis have cartilaginous connections in the young but fuse to become one bone by adult life. • the sacrum which wedges between the ilia • the coccyx, which comprises one or two bones and Each innominate bone articulates with its pair anteriorly at the symphysis pubis, thereby forming the which attaches to the sacrum, is formed from four pelvic girdle. On the lateral surface of each innominate a fused rudimentary vertebrae cup-shaped, deep depression forms the acetabulum for articulation with the femoral head. The acetabulum Tubercle of iliac crest -------\"-r -:--�·II Outer lip of iliac crest Iliac crest ___--�-, ,\\�,.\"';-;\" --7=\":;\"':'': <----- Anterior gluteal line i-;;=I lium -- ..,.--- ----- I nferior gluteal line --------7---�'-: -� Posterior gluteal line lIiopubic (iliopectineal) --------H.!- --=.,..:;.-: ;,.,=-:-7':-------- Acetabulum eminence �::=-T.:;-\"\",=\"'=-=-;;;�= \"'--- ---- Acetabular notch Pubic tubercle --.:;-,:j! -� Pubis -\"'=-_______ Ischium Ischial tuberosity Obturator foramen -\\0- -\"7.\"----- ---'- ,_--- Figure 1 1 .1 A: The lateral (external) view of the left innominate bone (reproduced with permission from Gray's anatomy 1995).

THE PELVIS 303 External ------\"\"7\"­\"- \\\\\\- --'T--------- External abdominal oblique Latissimus dorsi abdominal oblique -+------ Gluteus medius ----� Gluteus maximus Rectus femoris --_,- ____+_ jI)!(\\L Posterior superior iliac spine J/ Piriformis Posterior inferior iliac spine r---:��\"'-'-! --- +-------- Acetabulum Junction between ilium, -'\\'- Gemellus superior pubis and ischium Semimembranosus ) \\Pectineus --------T --4./Rectus abdominis, lateral head .//_ SJ 'Pyramidalis � :.r Biceps femoris and Adductor longus semitendinosus :\\\"-\"-_\"-Adductor brevis � '''_____---' - 'f---f-; --- ---- Quadratus femoris Gracilis ______ --;-=1---+---------- Obturator externus -==q�Junction between pubis _______ and ischium ---=:- \"'''-_- ______ Adductor magnus Figure 1 1 .1 B: Muscle attachments; the epiphyseal l ines are stippled (reproduced with permission from Gray's anatomy 1995). • a multitude of ligamentous structures which bind previously stable structures increases the potential for much of the pelvis together dysfunction and Gray's anatomy (1 995, p. 678) reports • Lee (1 999) includes the two femoral bones as part of the pelvic structure. that: The main function of the pelvic girdle is to offer a linkage 'Relaxation renders the sacro-iliac locking mechanism less mechanism between the upper body and the lower limbs effective, permitting greater rotation and perhaps allowing for locomotion; however, it also provides support for the alterations in pelvic diameters at childbirth, although the effect is probably small. The impaired locking mechanism diverts abdomen and pelvic organs (Gray's anatomy 1 995, p. 678). the strain of weight bearing to ligaments, with frequent sacro­ iliac strain [being noted ] after pregnancy. After childbirth Expandability of the pelvis during gestation and child­ ligaments tighten and the locking mechanism improves, but birth is augmented by hormonal involvements which this may occur in a position adopted during pregnancy. allow relaxation of supporting ligaments and therefore gradual and significant structural distortion. Note: Form and force closure mechanisms for the 51 joint Pregnancy and the pelvis are discussed fully later in this chapter. Levangie & Norkin (200 1 ) discuss the influences of The ligaments of the pelvis relax during pregnancy, making the joints they serve flexible for expansion and relaxin, a hormone produced during pregnancy which is often creating instability in the process. The relaxation of thought to activate the collagenolytic system. This system alters the ground substance by increasing its water content and decreasing viscosity and also regulates new collagen formation.

304 CLINICAL APPLICATION OF NMT VOLUME 2 Iliac fossa Figure 1 1 .2 A: The Iliac tuberosity _--'; medial (internal) view of the left innominate bone. B: Muscle attachments; the epiphyseal lines are stippled (reproduced with permission from Gray's anatomy 1995). Greater sciatic notch Anterior superior iliac spine Ischial spine ---I Anterior inferior iliac spine Lesser sciatic notch lIiopubic eminence Obturator foramen Ischiopubic ramus A --?,- ':�;;�e;��;;�;:Quadratus lumborum ________ I l iacus Transversus abdominis E rector spinae ----'-f. -- Sartorius ��Auricular surface -- ::c--: .::; :\":;r \"\"\" '--- Rectus femoris Psoas minor (one variation) ,��;;=;: __Obturator internus ________ �����----_T--------- Junction between ilium, ischium and pubis Coccygeus --+- Pubic tubercle Pubic crest Spine of ischium ---\\oL Levator prostatae l �Levator ani _______ Puborectalis � Levator ani Ridge for sacrotuberous -------f------, ligament Tuberosity of ischium ______ Sphincter urethrae Junction between ischium and pubis B '-_- ____ Transversus perinei superficialis

THE PELVIS 305 Iliolumbar ligament Lumbosacral ligament Anterior superior iliac spine 5th lumbar vertebra Anterior inferior iliac spine Anterior longitudinal ligament Iliopectineal eminence Ventral sacroiliac ligament Greater sciatic foramen Sacrospinous ligament (c.f. coccygeus) Ventral sacrococcygeal ligament Lesser sciatic foramen Sacrotuberous ligament Pectineal ligament Pubic tubercle Figure 1 1 .3 Joints and ligaments of the right half of the pelvis: anterior aspect. Anterior superior iliac spine and pubic tubercle are in the same coronal plane. Note the inclination of the 'brim' (inlet) of the lesser (true) pelvis, the boundaries of the sciatic foramina and the (partly obscure) pelvic outlet (reproduced with permission from Gray's anatomy 1995). Iliolumbar ligament -7- -\"'.+--- ::-;:-- --,-- Short posterior sacroiliac ligaments ..-,.'7 Sacrotuberous ligament --�--�.a- .,;,:;:-,--: Greater sciatic foramen Long posterior sacroiliac ligaments __��€'- Sacrospinous ligament Sacrotuberous ligament Superficial fibers of posterior Lesser sciatic foramen sacrococcygeal ligament Sacrotuberous ligament: ---='3----�+'- --''-' \"-.-- \" helical margin Falciform process -------0\"- :--: -:'-: :-: Figure 1 1 .4 Joints and ligaments on the posterior aspect of the right half of the pelvis and 5th lumbar vertebra (reproduced with permisSion from Gray's anatomy 1995).

306 CLINICAL APPLICATION OF NMT VOLUME 2 Sacral articular Sacral Iliac sacroiliac form closure mechanisms 'until such time as surface in articular articular the connective tissue tightens and rehabilitation for force surface in s u rface closure mechanisms is instituted'. SI rehabilitation is discussed later in this chapter. ventral The innominates As mentioned previously, each innominate is formed from three component bones, the ilium, ischium and pubic bone, and these elements can be described individually. Recumbent E rect The Ilium Figure 1 1 .5 The changing relation (rotation) of the auricular surface • A fan-shaped crest 'sinuously curves' (Gray's anatomy of the sacrum and that of the ilium when changing from a recumbent to an erect posture (reproduced with permission from Gray's anatomy 1995) as it connects the anterior superior iliac spine (ASIS) with the posterior superior iliac spine (PSIS - 1995). which is easily palpated beneath the 'dimpled' area approximately 4 cm lateral to the second sacral The action of relaxin is to decrease the intrinsic strength and spine). the rigidity of collagen and is thought to be responsible for the • The ASIS is palpable at the lateral end of the inguinal softening of the ligaments supporting the sacroiliac joints and fold. the symphysis pubis. Consequently, the joints become more • The lateral part of the ilium forms the superior aspect mobile and less stable and the likelihood of injury to these of the acetabulum, which hosts the head of the femur. joints is increased. The combination of loosened posterior • Inferior to the PSIS is the posterior inferior iliac spine ligaments and an anterior weight shift caused by a heavy (PIIS) which lies just posterior to the articular surface uterus may allow excessive movement of the ilia on the of the sacroiliac (SI) joint. sacrum and result in stretching of the sacroiliac joint capsules. • The articular surface, which forms the ilial portion of the SI joint, is L-shaped and is found on the Cyriax (1982) states that relaxin is present for up to posterosuperior aspect of the medial surface of each 3 months after pregnancy. In the authors' opinion, this is ilium. the ideal time to assess and deal with possible displace­ • The L-shaped articular surface has a long arm which ment of the pelvic bones which may have occurred as a runs anteroposteriorly and a short arm which runs result of pregnancy and / or labor. If possible, correction inferosuperiorly. of such situations should take place before the depletion • A number of important muscles and ligaments attach of relaxin firms the ligaments with the bones in in­ to the ilium including quadratus lumborum, erector appropriate positions. spinae, iliacus, transversus abdominis, rectus femoris, gluteus minim us, medius and maximus, sartorius, Lee (1999) reports that: tensor fasciae latae, obliquus abdominis externus and internus, latissimus dorsi and piriformis - see Figs The morphological changes within the pelvic girdle 1 1 . 1 8 and 11 .2B. associated with pregnancy are universal and often occur without symptoms. Occasionally, women present between the The ischium 26th and 28th weeks with increasing tenderness over the sacroiliac joint and / or pubic symphysis secondary to loss of • Each ischium forms one inferoposterior aspect of its kinetic function. Normally, the pelvic girdle returns to its respective innominate. prepregnant state between the 3rd and 6th months postpartum and simply requires external stabilization during this period. • Anterior to the border of the ischium is the obturator foramen. The type of stabilizing belt Lee suggests is worn just above the greater trochanters in order to augment • A tuberosity projecting from the body of the ischium ('sit bone') takes the weight of the upper body in sitting. • The superior part of the body of the ischium forms the floor of the acetabulum as well as a portion of the posterior part of the articular surface of the hip joint.

THE PELVIS 307 • A projection (ramus) anteromedially from the lower base) articulates with the 5th lumbar vertebrae at the aspect of the body of the ischium meets the inferior sacrovertebral angle. ramus of the pubis. • The dorsal surface of the sacrum is convex and the • There are a number of powerful muscular ventral surface concave. attachments to the ischium, most notably the • The sacral base is wide transversely with an hamstrings (biceps femoris, semimembranosus and semitendinosus) as well as quadratus femoris, anteriorly projecting edge, the sacral promontory. obturator externus and adductor magnus (see Figs • The sacral foramen is triangular in shape and 1 1 . 1 8 and 11 .2B). caudally is known as the sacral hiatus. Pubic bones • The superior, concave-shaped, articular processes of • The anterior aspect of the pelvis is formed by the the sacrum project cephalad, articulating with the junction of the two pubic rami at the symphysis inferior articular processes of the 5th lumbar pubis. vertebra. • Modified transverse processes and costal elements • The pubis links to the ilium superiorly by means of fuse together, and to the rest of the modified the superior pubic ramus which makes up the anterior portion of the acetabulum. vertebral structure, to form the sacral ala or lateral • The inferior pubic ramus joins the ischium at the mass. obturator foramen's medial aspect. • The ventral surface of the sacrum is usually vertically • A great many muscular attachments including and transversely concave. gracilis, adductors longus and brevis, pectineus and • The four pairs of sacral foramina have access to the rectus abdominis (lateral head) are connected to the pubis (see Figs 1 1 . 1 8 and 11 .2B). sacral canal via intervertebral foramina, through which the ventral rami of the upper four sacral The symphysis pubis nerves pass on the ventral surface. • Lateral to the foramina, costal elements merge and, • The junction of the two pubic bones is together with the transverse processes (also known as fibrocartilagenous, joined by the superior and the the costal elements), form the la teral aspect of the arcuate pubic ligaments. sacrum. • The dorsal surface of the sacrum has a sacral 'crest' • An interpubic disc connects the medial surfaces of with either three or four spinal tubercles, formed the pubic bones. from fused sacral spines. • Inferior to the lowest spinal tubercle is the sacral According to Gray's anatomy (1 995): 'Movements have hiatus formed by the failure of the 5th sacral segment's laminae to meet medially, so exposing the been little described. Angulation, rotation and displace­ dorsal surface of the 5th sacral vertebral body. ment are possible but slight . . . .some separation is said to • Fused laminae lie alongside the sacral tubercles and occur late in gestation and during childbirth' . Despite lateral to these are the dorsal sacral foramina (which Gray's suggesting that 'possible but slight' displacement lead to the sacral canal) through which run the dorsal rami of the sacral spinal nerves. can occur at the symphysis, osteopathic and chiropractic • Medial to the foramina runs the intermediate sacral clinical experience contradicts this apparent minimizing crest, composed of fused sacral articular processes, of the potential for pubic dysfunction. Pubic dysfunction the lowest pair (5th) of which is not fused and pa5terns, and suggested treatments, are described on projects caudally to form the sacral cornua on each p. 335 (Greenman 1996, Ward 1 997). side of the sacral hiatus. • The sacral cornua links with the coccygeal cornua by The sacrum means of the intercornual ligaments. • The female sacrum is shorter and wider than the • The lateral surface of the sacrum is formed from male's, as a rule (as is the pelvic cavity - see notes on pelvic classifications on p. 301 ). fusion of the vertebral transverse processes and costal elements. • The sacrum, a triangular fusion of five vertebrae, is • The inferior half of the lateral surface is L-shaped and wedged between the innominate bones to form the broad (auricular surface) and articula tes with the posterosuperior wall of the pelvic bowl. ilium (see p. 314, sacroiliac joint). • Posterior to the auricular surface is a rough area • The caudal end of the sacrum (the apex) articulates where ligamentous attachments occur (see later in with the coccyx while the flat cephalad aspect (the this chapter). • The sacral apex is formed from the inferior aspect of

308 CLINICAL APPLICATION OF NMT VOLUME 2 Lateral Attachment of Superior articular Multifidus part, interosseous Erector spinae Iliacus P romontory Pelvic upper sacroiliac sacral s u rface ligament foramen I nter­ mediate sacral crest and articular '-�- -\"#���__ tubercles _-'-- Inferior lateral angle Facet for Site of fusion Lateral maximus Sacral cornua coccyx between vertebral part bodies Lateral sacral crest and transverse tubercles Figure 11.6 Pelvic surface of the sacrum (reproduced with Median sacral crest and spinous tubercles permission from Gray's anatomy 1995). Figure 11.7 Dorsal surface of the sacrum (reproduced with permission from Gray's anatomy 1995). the 5th sacral vertebral body and has an oval facet • The sacrum's pelvic surface provides attachments for which articulates with the coccyx. piriformis muscles. • The sacral canal, as discussed, forms from fused sacral vertebral foramina, with the upper aspect of its • Running anterior to piriformis, having emerged from triangular opening pointing cranially when the the pelvic foramina, are the first three sacral ventral individual is in a standing position. rami. • The cauda equina, the filum terminale and the spinal meninges run through the sacral canal. • The sympathetic trunks and the median sacral vessels • The lateral walls of the canal open to the sacral descend medial to the foramina, directly in contact vertebral foramina while inferiorly the canal opens at with bony surfaces. the sacral hiatus. • The filum terminale (which attaches to the tip of the • Lateral sacral vessels descend lateral to the foramina, coccyx) exits from the sacral hiatus (as do the 5th also in touch with the bony surface. sacral spinal nerves) . • Attaching t o the ventral and dorsal surfaces o f the • The ventral surface of the upper sacral segments is first vertebral sacral body are terminal fibers of covered by parietal peritoneum and is crossed by the anterior and posterior longitudinal ligaments. The attachment of the sigmoid mesocolon. lowest pair of ligamentum £lava attach to the upper laminar borders. • The rectum is directly in contact with the pelvic surfaces of the 3rd, 4th and 5th sacral vertebrae. • The ala or lateral mass is smooth superiorly (covered by psoas major) and laterally rough where the • Erector spinae attach to the dorsal sacral surface, iliolumbar ligament attaches. Iliacus attaches to the overlying multifidus which also attaches to the anterolateral aspect of this area. sacrum. • The upper three sacral spinal dorsal rami penetrate these muscles as they emerge from the dorsal fora m i n a . • The auricular surface is covered by cartilage and has elevations cranially and caudally. Posterior to the

THE PELVIS 309 Superior Promontory The sacrum is therefore a glorified wedge, with all the articular refinement of design required to perform that role, as well as to allow passage through it of neural structures, process ---f to offer attachment sites to a variety of ligaments and muscles, and to engage in minute degrees of movement at the articulations between itself and the ilia. \"\"�'.___--_-' Remains of Nutation intervertebral discs The movement of the sacrum between the ilia involves a nodding motion, known as nutation, which creates an +-:--r�r: ri----- Sacral cornu anterior motion of the sacral promontory. Counter­ :--\"-;':=:�: l':+---- Coccygeal cornu nutation is the return to the neutral start position from a nutated position as well as a posterior motion of the I ntervertebral -:=____ Part of 1 st coccygeal segment sacral promontory. foramina in recently united to sacrum lateral wall of Bilateral sacral nutation and counternutation move­ sacral canal ments occur around a coronal axis within the interosseous ligament. Unilateral sacral nutation takes place when the lower extremity is extended. There is also a constant degree of alternating (muscularly) 'braced' nutation in the standing position (Dorman 1 997). Some muscular influences on sacroiliac function are discussed later in this chapter. Figures 1 1 .9 and 1 1 . 1 0 illustrate clearly the way in which the SI joint allows a gliding action of the sacrum to occur inferiorly (caudally) along the short arm and posteriorly along the long arm of the joint during nutation; during counternutation the sacrum glides anteriorly on the long-arm surface and superiorly (cephalad) along the short arm. The total degree of move­ ment which occurs in either nutation or counternutation does not exceed 2 mm, but is palpable (see palpation tests Figure 11.8 Median sagittal section through the sacrum (reproduced with permission from Gray's anatomy 1 995). auricular surface are depressions and roughened Sacral nutation attachment sites for interosseous sacroiliac ligaments. • Inferior to the auricular surface are a cluster of Inferoposterior attachment sites for gluteus maximus and coccygeus glide as well as the sacrotuberous and sacrospinous I tgaments. • Functions of the sacrum �/'�' 'A'\" Bogduk (1997) elegantly demystifies the role of the sacrum. !� '\\.. ':.. The sacrum is massive, but not because it bears the load of the '\\::. vertebral column. After all, the L5 vertebra bears just as much load as does the sacrum, but is considerably smaller. Rather, Figure 1 1.9 When the sacrum nutates, its articular surface glides the sacrum is massive because it must be locked into the inferoposteriorly relative to the innominate (reproduced with pelvis between the two ilia. The bulk of the sacrum lies in the permission from Lee 1 999). bodies and transverse elements of the upper two segments and the upper part of the third segment. These segments are designed to allow the sacrum to be locked into the pelvic girdle, and to transfer axial forces laterally into the lower limbs, and vice versa.

310 CLINICAL APPLICATION OF NMT VOLUME 2 � ;Sacral counter The greater the angle between the plane of the sacral base nutation and the vertical, the deeper the lumbar curve is likely to .. .• be, while the shallower the angle between the plane of the sacral base and the vertical, the flatter the lumbar Anterosuperior spine will be. The extreme angle seen with the third glide pelvic type involves the type of low back and pelvic orientation noted with spondylolisthesis, where L5 .. virtually slips anteriorly from the sacral base on which it should be supported. '.�� The coccyx Figure 11.10 When the sacrum counternutates, its articular surface glides anterosuperiorly relative to the innominate (reproduced with • The coccyx is composed of three, four (most permission from Lee 1 999). commonly) or five fused, rudimentary vertebrae. The first coccygeal vertebral body forms its upper surface, later in this chapter). Snijders et al (1997) report that or base, and articulates via an oval facet with the multifidus and levator ani act as a force couple, to help in sacral apex. control of the sacral nutation/counternutation processes. • Dorsolaterally to the facet lie two coccygeal cornua Sacral differences (see Fig. 1 1 . 1 1 ) which articulate with the sacral cornua superiorly. Lewit ( 1 985) pays tribute to the early work of Erdmann • A thin, fibrocartilagenous disc, somewhat thinner (1 956) and Gutmann (1965) into pelvic biomechanics: laterally, lies between the surfaces of the coccyx and sacrum. Gutmann and Erdmann distinguish three pelvic [sacral] types with far-reaching differences in function and possible • Rudimentary transverse processes project pathology. The first presents a long sacrum and high sacral superolaterally, which sometimes articulate and promontory [i.e the anterior projection of the sacral base, sometimes fuse with the inferolateral sacral angle, to reflecting the angle of the base to the vertical], the second the complete the 5th sacral foramina. average or intermediate type, and the third a low promontory and considerable pelvic inclination. • The 2nd to 4th coccygeal segments become progressively smaller, described by Gray's anatomy ( 1 995) as 'mere fused nodules'. • The levator ani and coccygeus muscles attach to the pelvic surface laterally. • The ventral sacrococcygeal ligament attaches ventrally to the 1 st and sometimes 2nd coccygeal bodies, as well as to the cornua. • Between the 5th sacral body and the cornua an intervertebral foramen allows passage of the 5th sacral spinal nerve. Table 1 1. 1 Different types of sacra (modified from Lewit 1 985) Type 1 Type 2 Type 3 High promontory Average promontory Low promontory Sacral base angle from vertical Above iliac crests 30-500 50-700 L4 disc position Level with iliac crests Below iliac crests Spinal curvature Flat Normal/average Increased X-ray findings As for type 1 Plumb line falls in front Plumb line from ear of promontory and hip joint Clinical consequences falls behind hip Blockage; L4 disc problems joint/promontory Arthrosis of lumbosacral, sacroiliac and hip joints ligament pain Hypermobile; L5 disc problems The muscular consequences of the different sacral types will vary considerably. However, it is predictable that the relative instability of type 1 could result in excessive protective musculoligamentous activity (for example, from hamstrings to help secure the sacroiliac jOints via the sacrotuberous ligaments) while the excessive depth of the lumbar curve of type 3 will result in extreme shortness in the lumbar erector spinae group and consequent inhibition of the abdominal musculature.

THE PELVIS 31 1 Vertical from Vertical from Vertical from Vertical from the outer meatus the promontory the outer meatus the promontory and to the base and to the base a A8 Vertical from Vertical from the promontory the outer meatus C Figure 1 1.1 1 Pelvic types showing (A) high promontory, (8) average type, (C) increased pelvic (sacral) inclination (adapted from Manipulative Therapy in Rehabilitation of the Locomotor System by K Lewil. Reprinted by permission of Elsevier Science Limited). • The dorsal surface of the coccyx has attachments for segment. This filament therefore represents a direct gluteus maximus, sphincter ani externus (at the very attachment of the meninges of the brain, via the tip) and the deep and superficial dorsal spinal dura, to the coccyx. Goodheart (1 985) has sacrococcygeal ligaments. described a positional release method involving the coccyx and the filum terminale. The objectives • The filum terminale lies between the deep and include easing spinal and pelvic dysfunctions relating superficial dorsal sacrococcygeal ligaments, merges to hypothesized dural restrictions (�ee Box 1 1 . 1 ) . with them and to the dorsum of the 1 st coccygeal

312 CLINICAL APPLICATION OF NMT VOLUME 2 Box 11. 1 Goodheart\"s filum terminale (coccygeal) lift technique coccygeal lift (there are prone position variations) to be effective. Note that the application of this method is contraindicated if there Goodheart (1 985) has described a method which seems to rely on is any inflammatory process in the coccygeal region. The method is the crowding, or slackening, of spinal, dural tissues with the coccyx unlikely to be successful (and could prove uncomfortable) if there being used as the means of achieving this. Good clinical results in has been a previous fracture of the coccyx, altering its normal terms of improved function and release of hypertonicity in local contours, to an 'I.: shape, for example. areas, as well as those some distance from the point of application, are claimed. Goodheart's term for this is a 'filum Method terminale cephalad lift'. • The patient is side lying and an area of particular sensitivity to Goodheart (1 985) and Walther (1 988) report that there is pressure is located in the cervical spinal area. frequently a dramatic lengthening of the spinal column after application of this coccygeal lift procedure, with Goodheart • The patient uses his own digital pressure to monitor the paiR mentioning specifically that, in good health, there should be no once the practitioner has identified it. A score of '10' is ascribed difference greater than about 1 inch in the measured length of the to the tender point and the objective is for this to reduce by at spinal column sitting, standing and lying, using a tapeless measure least 70% during the procedure. which is rolled along the length of the spine. • The practitioner stands at upper thigh level, behind the sidelying Goodheart (1 9 84) states: patient, facing the side of the table. Tension can be exerted where the foramen magnum is attached to • Using the lateral aspect of her cephalad hand (which should be relaxed and not tense throughout the procedure) she achieves the dura, and also at the 1st, 2nd and 3rd cervicals, which if they contact along the length of the coccyx as she tucks her cephalad elbow against her hip/abdomen area. are in a state of fixation can limit motion. The dural tube is • The force required to move the coccyx toward the head is completely free of any dural attachment all the way down to the applied by the practitioner leaning into the hand contact, not by any arm or hand effort. 2nd anterior sacral segment where finally the filum terminale • This application of pressure is not a push on the coccyx but a attaches to the posterior portion of the 1st coccygeal segment. The slowly applied easing of it toward the head and should cause no pain in the coccygeal region if introduced gently but firmly. release which comes from the coccygeal lift cannot be just a linear • Simultaneously the caudad hand holds the ASIS area in order to longitudinal tension problem. The body is intricately simple and stabilize the anterior pelvis and so be able to introduce fine tuning of its position during the 'lift', in order to reduce the simply intricate and once we understand the closed kinematic reported sensitivity score. chain and the concept of the finite length of the dura, we can see • As in positional release methods, the patient reports on the changes in palpated pain levels until a 70% reduction is how spinal adjustments can sometimes allow compensations to achieved. take place. • This position is held for 90 seconds after which reevaluation of dysfunctional structures is performed. Improvements in pelvic, spinal and cervical function have been reported (Goodheart 1 985, Walther 1 988) following use of the coccygeal lift. As in all positional release methods, tender areas are used as the means of monitoring the lift of the coccyx designed to produce the effects Goodheart describes. The tender areas employed are located in the neck flexor or extensor muscles. One of the authors (LC) has found the following version of the Ligaments of the pelvis the body (a syndesmosis is a fibrous articulation in which the bony surfaces are held together by interosseous The sacroiliac (S1) joint is supported by ligaments ventrally, ligaments). Bogduk (1 997) regards this structure as 'the dorsally and interosseously, as follows. most important ligament of the SI joint', the main func­ tion of which is to bind the ilium strongly to the sacrum. The ventral (or anterior) Slligament The dorsal (or posterior) Sl ligament This forms from an anteroinferior capsular thickening which is most developed near the arcuate line and the This covers the interosseous ligament, with the dorsal PIlS, from where it connects the 3rd sacral segment to the rami of the sacral spinal nerves and blood vessels lying lateral surface of the peri-auricular sulcus. Bogduk (1997) between them. There are short and long fibers which link suggests that it both helps to bind the ilium to the sacrum the la' and prevents anterior diastasis (slippage, separation) of the iliac crest. The short posterior SI ligament helps to the joint. stabilize, as well as preventing posterior flaring of, the joint. Additionally there are inferior posterior fibers The interosseous SI ligament which link the 3rd and 4th sacral segments to the PSIS. The long posterior SI ligament is continuous laterally This vast connection is the main bonding structure between with the sacrotuberous ligament (see below) and medially the sacrum and the ilium, filling much of the space with the thoracolumbar fascia. It has an additional role in posterosuperior to the joint. Covering it superficially is reducing the degree of backward rocking (counternutation) the dorsal SI ligament (below). Gray's anatomy (1 995, p. of the sacrum on the ilium (Bogduk 1 997). 675) describes this as the largest typical syndesmosis in

THE PELVIS 3 1 3 The sacrotuberous ligament The sacrospinous ligament The sacrotuberous ligament is really a vertebropelvic The sacrospinous ligament is a narrow triangular ligament although it has, via its connections, profound structure which attaches to the spine of the ischium and influence over the SI joint. Both it and the sacrospinous the lateral borders of both the sacrum and the coccyx, ligament (see below) reduce the opportunity for the where it blends with the sacrotuberous ligament. sacrum to tilt (nutate), by holding it firmly to the ischium (Bogduk 1 997). The sacrospinous ligament has as its anterior component the coccygeus muscle; that is, muscle and ligament are The ligament is attached at its cephalad end to the the anterior and posterior aspects of the same structure posterior superior iliac spine, blending with the dorsal SI ligaments, the lower sacrum and the coccyx, from where (Gray's anatomy 1 995). it runs via a thick narrow band which widens caudally as it attaches to the medial aspect of the ischial tuberosity. The sciatic foramina From there it spreads toward a merging with the fascial sheath of the internal pudendal nerves and vessels. The There are two sciatic foramina, the greater and the lesser. posterior surface of the sacrotuberous ligament hosts the The greater sciatic foramen has as its anterosuperior attachment of the gluteus maximus, while the superficial margin the greater sciatic notch, with the sacrotuberous lower fibers are joined by the tendon of biceps femoris. ligament forming its posterior boundary and the ischial spine and sacrospinous ligament providing its inferior Gray's (1995, p. 668) notes: borders. The piriformis muscle passes through it as do the superior gluteal vessels and nerves which leave the pelvis Many fibres of biceps femoris pass into the ligament, an via this route. Below the piriformis, a number of additional interesting fact, since the sacrum and posterior part of the structures exit the pelvis via the greater foramen, including ilium are primitive mammalian attachments of biceps femoris the sciatic nerve (usually), inferior pudendal nerve and - the tuberosity being a secondary attachment, the ligament vessels, inferior gluteal nerve and vessels, posterior representing, at least in part, remains of primitive tendon. femoral cutaneous nerves and the nerves to obturator internus and quadratus femoris (Heinking et aI 1 997). The ligament is penetrated by the coccygeal branches of the inferior gluteal artery, the perforating cutaneous The lesser sciatic foramen has as its boundaries the ischial body anteriorly, the ischial spine and the nerve and filaments of the coccygeal plexus (Gray's sacrospinous ligament superiorly and the sacrotuberous anatomy 1 995) ligament posteriorly. The tendon and nerve of obturator internus as well as the pudendal nerve and vessels pass The clinical significance of these attachments warrants through the foramen. emphasis. For example, as Van Wingerden et al (1 997) state: Note: Piriformis is a postural muscle, which will shorten Force from the biceps femoris muscle can lead to increased if stressed (Janda 1 983). The effect of shortening is to tension in the sacrotuberous ligament in various ways. Since increase its diameter and, because of its location, this increased tension in the sacrotuberous ligament diminishes the allows for direct pressure to be exerted on the sciatic range of sacroiliac joint motion, the biceps femoris can play a nerve, which passes under it in 85% of people. In the role in stabilization of the SIJ . . . In this respect, an increase in other 15% the sciatic nerve (or part of it) passes through hamstring tension might well be part of a defensive the muscle so that contraction could produce direct arthrokinematic reflex mechanism of the body to diminish muscular entrapment of the nerve (Beaton & Anson 1938, spinal load. Te Poorten 1 969, Travell & Simons 1 992). Such considerations should be kept in mind when SI joint In addition, the pudendal nerve and the blood vessels dysfunction or persistent hamstring tightness is noted, as of the internal iliac artery, as well as common perineal there would be little benefit in interfering with such a nerves, posterior femoral cutaneous nerve and nerves of protective mechanism by overenthusiastic treatment of a the hip rotators, can all be affected in a similar manner hamstring. (Janda 1 996). If the pudendal nerve and blood vessels, which pass through the greater sciatic foramen and reenter Also relevant is the knowledge that an active trigger the pelvis via the lesser sciatic foramen, are compressed point in biceps femoris may modify its own tone (Simons because of piriformis contractures, impaired circulation et al 1 999) and thereby influence SI joint stability (i.e. the to the genitalia will occur (in either gender). Since external muscle would have increased tone but may well be rotation of the hips is required for coitus by women, pain weaker than is appropriate, causing imbalances). This noted during this act, as well as impotence in men, could highlights the need for a trigger point search in muscles relate to impaired circulation induced by piriformis associated with dysfunctional joints. The eventual course dysfunction within the sciatic foramen. of therapeutic action may or may not involve deactivation of a trigger point in such a setting. See the discussion on trigger points and gluteus weakness on p. 366.

314 CLIN ICAL APPLICATION OF NMT VOLUME 2 Figure 1 1.12 Normal and idiosyncratic sciatic nerve positions in The greatest sacral movement relative to the iliac bones is in relation to the piriformis muscle (adapted from Ward 1 997). rising from a recumbent to a standing position . . .the sacral promontory advances as much as 5 to 6 mm as body weight The sacroiliac joint impinges on the sacrum . . . movement is not simple rotation . . .some translation is associated with it. The surfaces of the articulation between the sacrum and the ilium are reciprocally irregular, which restricts move­ Bogduk ( 1 997) explains the essential role of the 51 joints. ment and provides the joint with considerable strength as it transmits weight from the vertebral column and the The joint is placed strategically in the pelvic ring at the site of trunk to the lower limbs. There is an articular joint capsule maximum torsional stress in order to relieve that stress. In which attaches close to both articular margins. teleological terms, a solid ring of bone will not work; it will crack, and the 51 joint is there to anticipate that crack. With age, in both genders, fibrous adhesions and other changes gradually obliterate the joint. 'In old age the joint Indeed, the evidence is that when the 51 joint fuses, as it may be completely fibrosed and occasionally even ossified' does in some people due to age or disease (ankylosing spondylitis, for example), the sacrum does literally crack, (Gray's anatomy 1 995, p. 675). Clinically, these changes are especially if weakened by osteoporosis (Lourie 1 982) . Bogduk ( 1 997) reports: important as radiographic research has demonstrated that even before age 50, 6% of joints show evidence of a Under these conditions the torsional stresses, normally degenerative process (Cohen et al 1967). buffered by the 51 joint, are transferred to the sacrum which fails by fracture. Conspicuously and strikingly, these fractures SI joint movement run vertically through the ala of the sacrum parallel to the 51 joint. A very small amount of anteroposterior rotation occurs around a transverse axis when the trunk is flexed or The current understanding of the 51 joint is therefore extended, with the degree of movement increasing that it performs stress absorption functions as forces from above or below are transferred into the pelvic mechanism. during pregnancy. According to Gray's anatomy ( 1 995): These forces are partially absorbed into the enormous and powerful ligamentous support which the joint enjoys and partially into the unique mechanical relationship the sacrum has with the ilia, where an osseous locking device allows transfer of forces into the pelvis as a whole. Bogduk ( 1 997) again succinctly summarizes the way in which the functional needs of the 51 joint have been accommodated into its design. For its longitudinal fW1Ctions, it will exhibit osseous features that lock it into the pelvic ring. For its anti-torsion functions it will exhibit, in a parasagittal plane, a planar surface that can allow gliding movements, but it will be strongly reinforced by ligaments that both retain the locking mechanism, and absorb twisting forces. These functional needs have been superbly incorporated into the 51 joint's design. Self-locking mechanisms of the SI joint Two mechanisms lock the joint physiologically and these are known as 'form closure' and 'force closure' mechanisms. Form closure is the state of stability which occurs when the very close-fitting joint surfaces of the 51 joint approxi­ mate, in order to reduce movement opportunities. The efficiency and degree of form closure will vary with the particular characteristics of the structure (size, shape, age) as well as the level of loading involved. Lee (1 999) states: In the skeletally mature, 5 1 , 52 and 53 contribute to the formation of the sacral surface [of the 51 joint] and each part can be oriented in a different vertical plane. In addition the

THE PELVIS 31 5 sacrum is wedged anteroposteriorly. These factors provide Muscle activity and the SI joint when walking resistance to both vertical and horizontal translation. In the young, the wedging is incomplete, such that the 51 joint is Dorman (1 995) analyzed muscular activity relating to 51 planar at all three levels and is vulnerable to shear forces until fu nction during the gait cycle. ossification is complete (third decade). • Erector spinae 'might be expected to promote nuta­ Force closure refers to the support offered to the 51 joint tion'. Dorman (1 995) suggests that select subsegments of by the ligaments of the area directly, as well as the various this group might fire independently when required . sling systems which involve both muscular and ligamen­ tous structures (see discussions within this chapter) • Gluteus maximus promotes self-locking of the 51 (Vleeming et al 1997). joint and controls nutation when the fibers which attach to the sacrotuberous ligament contract. This is clearly a Examples of 'force closure' are: secondary function of gluteus maximus and would only operate in particular postural and nutation positions. • during anterior rotation of the innominate or during sacral counternutation, the 51 joint is stabilized by a • Gluteus medius has a distinctive role to play in lock­ tightening of the long dorsal sacroiliac ligament ing the 51 joint during the stance phase of the gait cycle. However, Dorman ( 1 997) suggests that it is subject to • during sacral nutation or posterior rotation of the reflex inhibition when the ilium on the affected side is in innominate, the 51 joint is stabilized by the an anterior position, at which time tenderness will be sacrotuberous and interosseous ligaments. noted on deep palpation under the rim of the iliac crest (sidelying). A summary of muscular involvements in these processes is outlined below. • Latissimus dorsi joins across the mid-line with the contralateral gluteus maximus via the thoracolumbar Innervation of the SI joint fascia and activates during trunk rotation (which occurs during gaiting). The thoracolumbar fascia can also be Bogduk (1 997) reports that there is little in the way of tightened by the erector spinae. The effect is to stabilize authoritative evidence to support various contradictory the 51 joint. claims as to the precise innervation of the joint. Lee ( 1 999) reports that there is evidence that posteriorly the 51 joint • Biceps femoris can change the tension of the sacro­ is supplied from the posterior rami of the 51 and 52 tuberous ligament, modulating its tension and influencing spinal nerves (5010nen 1 957); that the dorsal 51 ligaments the 51 joint. This influence varies with body position and (and probably the joint) are supplied from lateral divi­ the degree of nutation. sions of the dorsal rami of L5, 51, 52 and 53 spinal nerves (Bradlay 1985), while the lateral branches of L5, 51 and 52 Slings, units and systems dorsal rami form a plexus between the interosseous and dorsal sacroiliac ligaments (Grob 1 995). There was Lee ( 1 999) discusses muscular contributions to the contradictory research evidence from 5010nen and from stability of the pelvic structures (as well as the lumbar Grob as to the ventral neural supply to the 51 joint, which spine and the hip) and points out that there are two apparently varied considerably between different indivi­ muscular 'units' involved, an inner and an outer. duals. Lee asserts: 'The wide distribution of innervation is reflected clinically in the variety of pain patterns The inner unit includes: reported by patients with 51 joint dysfunction' . • the muscles of the pelvic floor (primarily levator ani Muscles and the SI joint and coccygeus) According to Bogduk (1 997) there are no muscles which • transversus abdominis actively move the 51 joints; however, a great many muscles • multifidus and attach powerfully on either the sacrum or the ilia and are • the diaphragm. therefore capable of strongly influencing the functional adequacy of the pelvis as a whole and of 51 joints in The outer unit comprises four 'systems' : particular. • Posterior oblique system (latissimus dorsi, gluteus Dorman (1 997) suggests that: 'Judging by their attach­ maximus and the lumbodorsal fascia which links them). ments, various muscles are probably involved, directly or When latissimus and contralateral gluteus maximus indirectly, in force closure of the 5IJ ' . Indirectly muscles contract there is a force closure of the posterior aspect of can act on ligaments and fascia (see the discussion the 51 joint. regarding the influence of the hamstrings on the sacro­ tuberous ligament on p. 379). • Deep longitudinal system (erector spinae, deep laminae of the thoracodorsal fascia, sacrotuberous ligament and biceps femoris). When contraction occurs, biceps femoris influences compression of the 51 joint and

31 6 CLINICAL APPLICATION OF NMT VOLUME 2 Multifidus D i a p h ragm Lee (1999) succinctly summarizes the possibilities. Transversus Weakness, or insufficient recruitment and/or timing, of the Abdominis muscles of the inner and / or outer unit reduces the force closure mechanism through the S1 joint. The patient then adopts compensatory movement strategies to accommodate the weakness. This can lead to decompensation of the lower back, hip and knee. As these structures weaken or modify, spread of dysfunction to other body parts will also be seen, from the feet to the cranium. Sacrum Pelvic floor Leg croSSing - a muscular benefit? Figure 1 1 .1 3 The muscles of the inner unit include the multifidus, Dorman (1 997) asks: 'Do any muscles maintain a state of transversus abdominis, diaphragm and the pelvic floor (reproduced continuous contraction to maintain the state of force with permission from Lee 1 999). closure - bracing - of the 51 articulations?' The answer is somewhat surprising. It was found on EMG testing that sacral nutation can be controlled (Van Wingerden et al during normal standing and sitting there was no firing of 1993). either biceps femoris or gluteus maximus but there was an almost constant firing of the internal oblique abdominal • Anterior oblique system (external and internal muscles (Dorman 1 997) . Firing of the internal obliques obliques, the contralateral adductors of the thigh and the almost ceased, however, when the legs were crossed ! It is intervening abdominal fascia). The obliques take part in thought that, because trunk rotation takes place, when most upper and lower limb as well as trunk movements, cross-legged, the fascial tube of the body is placed under with transversus abdominis stabilizing. The obliques act some slight tension, thereby maintaining compression on almost constantly in unsupported sitting, although cross­ the pelvis and allowing the oblique abdominals to relax. legged posture allows them 'time-out' (see the discussion As Dorman points out: 'When [muscles) do not relax of this phenomenon later in this chapter). Snijders et al fatigue, spasm and trigger points develop'. (1 997) suggest that cross-legged sitting offers stabilization for the SI joint, obviating the need for force closure. The mechanism of crossing the legs when seated there­ fore apparently produces temporary release of these • Lateral system (gluteus medius and minimus and overworked muscles (Snijders et al 1 995). However, as contralateral adductors of the thigh). Lee (1 999) reports Dorman elaborates: that: 'Although these muscles are not directly involved in force closure of the SI joint they are significant for the [During cross legged sitting] the ischium is subject to function of the pelvic girdle during standing and walking increased weight bearing, and the tension measured in the and are reflexively inhibited when the SI joint is latissimus dorsi of the one side and the gluteus maximus of unstable'. the other is increased. This balance can be maintained for some time, but creep in the soft tissues is apt to give enough Practitioners might reflect on circumstances which slack after an interval, which will reflexly 'wake up' the would create imbalances in the force closure mechanisms 'guardian' internal oblique muscles. It is now that the sitting which so carefully support the SI joint. Anything which subject instinctively reverses, changes over to crossing the inhibits the primary players in this process should be other leg, an experience we have all noticed subjectively. suspect, including: GAIT AND THE PELVIS • excessive tone in antagonists to gluteus maximus, minimus and medius, biceps femoris, lumbar erector In Chapter 3 the gait cycle is discussed in all its complexity. spinae, multifidus, adductor and abductors of the In this section the effects of walking (on the pelvis in thigh as well as the oblique abdominaIs and general and the 51 joint in particular) are summarized transversus abdorninis (Lee 1 997, Schafer 1 987, Vleeming et aI 1 997) . • inhibition, which may also derive from local or Understanding the role that muscles, tendons and referring trigger points fascia play in the act of walking requires awareness of the concept of energy storage by these structures. See • other forms of local muscular dysfunction Chapter 3 for notes on energy storage. (inflammation, fibrosis, etc.) • During the swing phase of gait, as the right leg moves • joint restrictions. forward, the superior aspect of the ilium rotates posteriorly while the sacral base inclines anteriorly. (Fig. 11 .14).

THE PELVIS 31 7 Gluteus maximus Sacrotuberous ligament Vastus lateralis Patella Tibialis anterior A B � ��=-�L-__ �__� ��____ ______ __________ ___ Figure 1 1 .1 4 A: Lower part of the oblique dorsal muscle-fascia-tendon sling. Relationship between the gluteus maximus, iliotibial tract, vastus lateralis muscle and knee in a single support phase. The iliotibial tract can be tensed by action of the dorsally located gluteus maximus and ventrolaterally located tensor fascia latae muscle. The tract can also be tensed by contraction of the vastus lateralis. B: The longitudinal muscle-tendon-fascia sling. Relationships at the end of the swing phase (reproduced with permission from Vleeming et al 1 997). • As this happens, sacral nutation and ligamentous latissimus dorsi which assists in counterrotation of the tension increase on the right and the 51 joint is com­ trunk on the pelvis. pressed as the joint prepares for heel strike and weight bearing. • This effectively creates an oblique muscle-fascia­ tendon sling across the torso which creates a further • Just before heel strike, activation occurs in the energy store for use in the next phase of the cycle. ipsilateral hamstrings, thereby stabilizing the extended knee and tightening the sacrotuberous ligament to • 50me of the gluteal tension is also transferred into further stabilize the 51 joint. the lower limb via the iliotibial tract. • Vleeming et al ( 1 997) have demonstrated that as the • Vleeming et al ( 1 997) describe what happens next: foot approaches heel strike there is a downward 'In addition, the iliotibial tract can be tensed by movement of the fibula, increasing (via biceps femoris) expansion of the huge vastus lateralis muscle during its the tension on the sacrotuberous ligament, while simul­ contraction . . . during the single support phase, this taneously the tibialis anterior (which attaches to the first extensor muscle is active to counteract flexion of the metatarsal bone) fires, in order to dorsiflex the foot in knee'. They point out that the iliotibial band merges with preparation for heel strike. the outer lateral capsule of the knee, with the fibers running perpendicular to the patella tendon which • Tibialis anterior links to peroneus longus under the attaches to the tibia. foot, thus completing the sling mechanism. • Protection of the knee from forward shear forces is • Biceps femoris, tibialis anterior and peroneus longus therefore available during the single support phase by together form this longitudinal muscle-tendon-fascial the integrated and combined actions of the thoracolumbar fascia, gluteus maximus and the iliotibial tract. sling which is loaded to create an energy store (loaded elastic element), to be used during the next part of the • As the single support phase ends and the double gait cycle. support phase initiates, there is a lessened loading of the 51 joints and gluteus maximus reduces its activity. • During the brief single support phase of the gait cycle, biceps femoris activity reduces as compression of • As the next step starts, the leg swings forward and the 51 joint reduces and the ipsilateral innominate bone nutation at the 51 joint starts again. rotates anteriorly. THERAPEUTIC CONSIDERATIONS • At this stage, as the right heel strikes and the left arm swings forward, gluteus maximus activates to compress In general terms, when imbalances, distortions and /or and stabilize the 51 joint, as well as to provide coupling functional changes have occurred in the low back and /or (via the thoracolumbar fascia) with the contralateral

31 8 CLINICAL APPLICATION OF NMT VOLUME 2 pelvis (or elsewhere), restoration of normal function end . A deeper discussion of these concepts is to be found requires that a logical sequence of therapeutic and in Volume 1 , Chapter 4. rehabilitation strategies are employed. PELVIC PROBLEMS AND THE LOW BAC K Potential soft tissue and joint restrictions, shortening of myofascial tissue and dysfunctions (e.g. trigger points) Almost all problems of the lumbar spine will create need to be assessed and treated appropriately in order to stresses involving the pelvis and all pelvic dysfunctions restore an optimal degree of voluntary control. and imbalances place adaptation demands on the lumbar spine, making it essential to consider the lumbar-pelvic Appropriate treatment requires lengthening of what is mechanisms as a continuum (Schafer 1 987) . short, strengthening of what is weak, mobilization of what is restricted ('blocked'), deactivation of trigger points, A common feature of low back and pelvic dysfunction reintegration of functional patterns of use, etc. In order involves an unbalanced pattern known as the 'lower for this to be achieved, sound evaluation and assessment crossed syndrome', first described in detail by Janda methods are required. And within this evaluation there is (1 982, 1 983). This dysfunctional pattern is the result of a a need to maintain awareness that some apparently chain of events in which particular muscles shorten and dysfunctional states are, in fact, protective and are part of others are inhibited in response to stresses imposed on the way the body is best handling its adaptive responses. them. A more complete evaluation of the underlying causes may therefore be required before the tissues which are actually As Greenman (1 996) explains: 'Muscle imbalance serving to stabilize and protect can be safely released. See consists of shortening and tightening of muscle groups Chapter 1, pp. 26-27 for discussion of the role of trigger (usually the tonic [ 'postural'] muscles), weakness of certain points as possible protectors of normal function. muscle groups (usually the phasic muscles), and loss of control on integrated muscle function'. The term Following appropriate therapeutic interventions, when 'pseudoparesis' is used by Janda ( 1 983) to describe the (even partial) voluntary control of an area has been reciprocal inhibition-related weakness of phasic muscles, achieved, reflex (automatic) control needs to be encouraged as compared with true weakness. and regained . This protocol involves retraining and rehabilitation strategies which help the individual to alter Lower crossed syndrome habitual patterns of use which may have contributed to the original dysfunctional situation. The lower crossed syndrome involves the following basic imbalance pattern: Iliopsoas, rectus femoris, TFL, the short The suggested therapeutic sequence therefore involves adductors of the thigh and the erector spinae group all assessment � local treatment � general treatment � tighten and shorten, while the abdominal and gluteal rehabilitation, with an overlap occurring between all muscles all weaken (i.e. are inhibited). The result of this these stages. Rehabilitation/self-help strategies should chain reaction is to tilt the pelvis forward on the frontal commence early, with general and local therapeutic plane, while flexing the hip joints and exaggerating strategies often taking place during the same session, lumbar lordosis. LS-Sl will have increased likelihood of while assessment is continuous throughout the process. soft tissue and joint distress, accompanied by pain and irritation. An additional stress feature commonly appears Homeostatic subtext in the sagittal plane in which quadratus lumborum shortens and tightens, while gluteus maximus and The key subtext of the discussion in Box 1 1 .2 is that the medius weaken. body and the local structures/ tissues are self-regulating, self-healing and have a propensity for recovery if causa­ When this 'lateral corset' becomes unstable the pelvis tive factors are eliminated or eased. Causative factors fall is held in increased elevation which is accentuated when into one of two categories: they are either factors which walking ('hip hike') as quadratus fires inappropriately. are loading the adaptive mechanisms of the body (through This instability results in LS-Sl stress in the sagittal overuse, misuse, abuse or underuse, for example) or they plane, which leads to lower back pain. These combined represent a failure of the adaptive functions. Treatment, stresses produce instability at the lumbodorsal junction, of whatever sort, therefore needs to aim at reducing the an unstable transition point at best. The relative weakness/ adaptive load while assisting in enhancing function to inhibition of gluteus maximus has implications for 51 better handle the load. joint stability during the gait cycle, as explained earlier in this chapter. Appropriate treatment therefore encourages self­ healing, which is why so many different methods can The piriformis muscles are also commonly involved. achieve similar ends. It is the self-regulating (homeostatic) Since in approximately 20% of individuals, the right mechanisms which normalize and heal, not the applied piriformis is penetrated by either the peroneal portion of trea tment. Treatment can only be a catalyst toward that

THE PELVIS 319 Box 11.2 Questions regarding therapeutic intervention In this book, when the reader is confronted by a series of tissues which are not responding may do so beautifully after the descriptions of therapeutic modalities and procedures it will be all joints have been mobilized. All the procedures listed will 'work' - if too easy to wonder which should be chosen in relation to treating a particular condition. For example, in the description of sacroiliac they are appropriate to the needs of the dysfunctional region and if dysfunction and pain, a variety of strategies are offered for normalizing the restricted joint. The following queries serve to guide they encourage a re storation of functional integrity. decisions regarding protocols, while still maintaining diverse choices based upon what is found in examination. a. Should trigger points be located and deactivated and, if so, in which stage of the therapeutic sequence and which treatment a. Should manipulation/mobilization techniques of the joint be approach should be chosen? used? A. Trigger points may be major players in the maintenance of A. Possibly; however, in the experience of the authors, soft tissue dysfunctional soft tissue status. Trigger points in the key muscles imbalances which might be causing or maintaining the problem are associated with the SI joint, or antagonists/synergists of these, usually best dealt with first. Manipulation of the joint may require could create imbalances which would result in SI joint pain. Trigger referral to an appropriately licensed practitioner and usually best points may therefore (and usually do) need to be located and follows the creation of a suitable soft tissue environment in which treated early in a therapeutic sequence aimed at restoring normal shortness/weakness imbalances have been lessened. The SI joint function, using methods with which the practitioner is information in this chapter has shown just how complex muscular familiar (and licensed to perform), whether this be procaine and ligamentous influences on the SI joint can be. For instance, as injections, acupuncture, ultrasound, spray-and-stretch techniques described above, during walking there is a 'bracing' of the or any suitable manual approach ranging from ischemic ligamentous support of the SI joint to help stabilize it, involving all compression to positional release and stretching or indeed a or any of the following muscles: latissimus dorsi, gluteus maximus, combination of these methods. What matters is that the choice of iliotibial band, peroneus longus, tibialis anterior and more (Dorman method is logical, non-harmful and effective and that the 1 997). Since any of these muscles could conceivably be involved in practitioner has been well trained to use it. maintaining compression/locking of the joint, they should be considered and evaluated (and if necessary, treated) when Additionally, there may be times (as discussed elsewhere within dysfunction of the joint occurs, prior to manipulation of the joint. this text) when trigger points may be serving a protective or stabilizing role to a more complex compensatory pattern. Their a. Should muscles attaching to the pelvis be evaluated for treatment may then be best left until after correction of the shortness/weakness and treated accordingly? adaptational mechanisms which have caused their formation. A. Almost certainly, as any obvious shortness or weakness in Indeed, with correction of the primary compensating pattern muscles attaching to the pelvis is likely to be maintaining (forward head position, for instance), the trigger points (in this dysfunctional patterns of use, even if it was not part of the original case, masticatory muscles) may spontaneously deactivate without cause of the SI joint problem. Any muscle which has a working intervention when the forward head position and possibly resulting relationship (e.g. antagonist, synergist) with muscles stabilizing the SCM trigger points are corrected (Simons et al 1 999). SI joint could therefore be helping to create an imbalance and should be assessed for shortness and/or weakness. However, it a. When should postural reeducation and improved use patterns should always be kept in mind that what is observed is an adaptive (e.g. sitting posture, work habits, recreational stresses, etc.) be compensation and the underlying causes should be sought and addressed? corrected as a primary concern. A. The process of reeducation and rehabilitation should start early on, through discussion and provision of information, with homework a. Should MET or PRT or MFR or NMT or mobilization or HVT or starting just as soon as the condition allows (e.g. it would be other tactics be used? damaging to suggest stretching too early after trauma while A. Yes, to most of the above ! The choice of procedure, however, consolidation of tissue repair was incomplete or to suggest should depend on the training of the individual, the degree of postures which in the early stages of recovery caused pain). The acuteness/chronicity of the tissues being treated and the tissue's more accurately the individual (patient) understands the reasons response when the modality is applied. The more acute the why homework procedures are being requested, the more likely is situation, the less direct and invasive the choice of procedure a satisfactory degree of compliance. should be, calling for positional release methods initially, for example. HVT should be reserved for joints which are non­ a. Should factors other than manual therapies be considered? responsive to soft tissue approaches and in any case should follow A. Absolutely! The need to always keep in mind the multifactorial a degree of normalization of the soft tissues of the region, rather influences on dysfunction can never be overemphasized. than preceding soft tissue work. Occasionally, however, the soft Biochemical and psychosocial factors need to be considered alongside the biomechanical ones. For discussions on this vital topic, see Chapter 1 and also Volume 1 , Chapter 4 and its Fig. 4 . 1 for details of the concepts involved. the sciatic nerve or, rarely, by the whole nerve (the inci­ syndrome pattern is that stresses will translate superiorly, dence of this is apparently greatly increased in individuals thereby triggering or aggravating an upper crossed of Asian descent), non-disc related sciatic symptoms may syndrome pattern (described fully in Volume 1 , Chapter result but are rarely noted beyond the knee when 5). We readily see in these examples how the upper and entrapment of the nerve is due to piriformis. (Heinking et al 1 997, Kuchera & Goodridge 1 997). lower body interact with each other, not only functionally but dysfunctionally as well. Treatment sequencing The solution for patterns such as the lower crossed An almost inevitable consequence of a lower crossed syndrome is to identify both the shortened and the weakened structures and to set about normalizing their dysfunctional status. This might involve:

320 CLINICAL APPLICATION OF NMT VOLUME 2 TighVshort I n h i bited excessively active, as will the ipsilateral erector spinae e rector abdominal (which should be bracing the low back and not acting as spinae, muscles hip extensors through their action of extending the lumbar spine). If, on the other hand, the neutralizers quadratus TighVshort and /or the fixators are weak, the basic pattern persists l u m bo r u m iliopsoas, but there is accessory motion; if the antagonists are weak, rectus femoris, the range of motion is increased (Vasilyeva & Lewit 1996). Inhibited quadriceps, gluteal tensor fascia latae, Clinical example adductors muscles Vasilyeva & Lewit (1996) describe an example of the reper­ cussions of a weakened (inhibited) gluteus maximus, in Figure 1 1 . 1 5 lower crossed syndrome (after Janda) (reproduced which the hamstrings and erector spinae are overactive. with permission from Chaitow & Delany 2000). (Fig. 1 1 . 16). • deactivating trigger points within the dysfunctional Consider the attachments of gluteus maximus which (short/weak, etc.) muscles or trigger points which are (on the pelvic end) to the ilium behind the posterior might be influencing them, such as those located in gluteal line, lower posterior part of sacrum, lateral synergists or antagonists aspect of coccyx, sacrotuberous ligament, lumbodorsal aponeurosis and fascia of gluteus medius and (on the • normalizing the short and /or weak muscles, with the femoral end) to the iliotibial band of fascia latae and the objective of restoring balance. This may involve gluteal ridge of the femur. purely soft tissue approaches or be combined with osseous manipulation and rehabilitation exercises If the muscle is inhibited (weakened reciprocally by overactive antagonists including biceps femoris and the • reeducating posture and body usage, if results are to erector spinae group, or by the presence in it, or in func­ be other than short term. tionally related muscles, of active trigger points) (Simons et a 1 1 999), there will be a series of changes including: • anteversion and external rotation of the innominate • anteversion and ipsilateral flexion and rotation of the sacrum • hyperlordosis of the lumbar spine with a tendency to scoliosis toward the ipsilateral side Recognizing inappropriate firing sequences AB C An additional consequence of muscle dysfunction is a Figure 1 1 .1 6 Changes in body outline because of weakness of the tendency for firing sequences to become unbalanced, so gluteus maximus. Front view (A), side view (B), back view (C) (adapted that synergists adopt the role of prime mover in important with permission from Liebenson 1 996). movement patterns. For example, what happens if the main culprits in disturbed motor patterns are weak muscles, inhibited by overactive antagonists? The thres­ hold of irritation in the weakened muscle is raised and therefore, as a rule, the muscle contracts later than normal or, in some cases, not at all. This alters the order in which muscles contract and leads to poor coordination between prime movers, synergists and antagonists. The most characteristic feature is substitution, which alters the entire pattern. This change is particularly evident if the weak muscle is the agonist in a particular movement sequence (see tests below). For example, when testing for movements such as prone hip extension, if the gluteus maximus has weakened, the hamstrings (which should be assisting gluteus maximus, not dominating it) will be

THE PELVIS 321 • contralateral deviation of the lower part of the restriction, muscular shortness, weakness and /or co­ sacrum and coccyx ordination features is under way, the aberrant behavior of local trigger points may calm down. On the other hand, • flexion, adduction and internal rotation of the thigh trigger point deactivation may be a requirement for that in the acetabulum very rebalancing process to proceed. Additional discussion is found in Volume 1 , Chapter 4. • flexion, adduction and internal rotation of the knee. Further observation may also alert the practitioner to Observation would show: the presence of a crossed syndrome (see Fig. 1 1 .1 5), in which the pelvis is tilted anteriorly, the abdomen pro­ • an increase in the transverse diameter of the pelvis trudes and there is increased thoracic kyphosis, with the and the hip head thrust forward, with rounded shoulders, etc. How the individual stands and moves offers important obser­ • the greater trochanter would be displaced superiorly vational clues as to underlying patterns of dysfunction, and protruding thereby guiding the practitioner toward which structures deserve closer attention, testing and evaluation. • the upper margin of the ilium would be tilted anteriorly with the ASIS low SCREENING • the PSIS would be closer to the sacrum than normal How is the practitioner to know which muscles, among • there would be a valgosity at the knee with the the many involved in pelvic function and dysfunction, display relative shortness, weakness and /or inappropriate patella medially translated firing sequences? • the hip and knee joints would be held in slight Testing and a rapid screening procedure are needed, flexion. involving functional tests (below) as well as assessment of length and strength, which can usually identify the The patterns of pain and dysfunction which would emerge precise dysfunctional features of a condition. A number would be predictable, involving back, pelvic, hip, knee of these tests associated with particular regions and joints and foot pain, with a transference of stress superiorly as are detailed in this text and its companion. Several func­ well, throwing the upper body into a compensating pattern tional assessments directly relating to the pelvic imbalance, of adaptive stress. as described above, are of clinical importance and are included in the following section. Possible trigger point involvement Janda's functional tests In what way may trigger points be playing a part in such patterns of dysfunction? Trigger points are activated when Janda ( 1 996) has developed a series of functional assess­ the myofascial tissue is overloaded (strained, overused), ments which can be used to show changes which suggest shortened (especially repetitively, prolonged or abruptly), imbalance, by providing evidence of over- or under­ traumatized, chilled or as a result of low oxygenation of activity. Some of these directly related to the lumbar and the tissues, systemic biochemical imbalance (e.g. hormonal, pelvic area are outlined below. Greenman (1 996) elaborates nutritional) or febrile illness (fever) (Simons et al 1 999) . on the means whereby these assessments have been validated. According t o Simons e t al (1 999), an active trigger point will inhibit the function of a muscle in which it is Muscle dysfunction is not only characterized by facilitation housed as well as those which lie in its target zone of and inhibition but also in the manner in which muscles referral. Therefore, the trigger points may be in the weak sequentially fire. Altered muscle firing patterns show delay in muscle or in a muscle which refers into it, or both. activation and in the amplitude of electromyographic activity in the dynamic-phasic muscles. Continued exercise in the Although weakness is generally characteristic of a muscle with presence of abnormal muscle firing sequences perpetuates active myofascial trigger points, the magnitude is variable hypertonicity, tightness and shortening of the tonic muscles from muscle to muscle, and from subject to subject. EMG with continued and progressive inhibition of the phasic studies indicate that, in muscles with active trigger points, the muscles. muscle starts out fatigued, it fatigues more rapidly, and it becomes exhausted sooner than normal muscles. The evolution of myofascial trigger points, in both the bellies and attachments of muscles stressed in this way, is As noted, weakness may also be a reflection of inhibition inevitable (Simons et al 1 999). referred from a trigger point in another muscle. A clinical decision might be made to treat active trigger points as a Altered movement patterns can be tested as part of a primary goal of the therapeutic strategy. Alternatively, screening examination for locomotor d ysfunction. In other dysfunctional features (such as structural imbalances, biochemical (e.g. nutritional) imbalances or breathing dysfunction) might attract primary attention and the trigger point(s) could be monitored to evaluate changes in activity. If a release and balancing of local joint

322 CLINICAL APPLICATION OF NMT VOLUME 2 general, observation alone is all that is needed to deter­ substantially delayed . . . the leg lift is achieved by mine the altered movement pattern. However, light pelvic forward tilt and hyperlordosis of the lumbar palpation may also be used if observation is difficult due spine, which undoubtedly stresses this region' . to poor lighting, a visual problem or if the person is not sufficiently disrobed. Va ria tion Although some of these tests relate directly to the • When the hip extension movement is performed the lower back and limb, their relevance to the upper regions lower limb should be observed to be 'hinging' at the of the body should be clear, based on the interconnectedness hip joint. of body mechanics. • If, instead, the hinge seems to take place in the Prone hip extension test (see Volume I, Fig. 5.3, lumbar spine, the indication is that the lumbar spinal extensors have adopted much of the role of gluteus p. 60) maximus and that these extensors (and probably hamstrings) will have shortened. • The person lies prone and the practitioner stands to the side at waist level with the cephalad hand Hip abduction test (Fig. 11 . 1 7) spanning the lower lumbar musculature and assessing erector spinae activity. • The person lies on the side, ideally with his head on a cushion, with the upper leg straight and the lower leg • The caudal hand is placed so that the heel lies on the flexed at hip and knee, for balance. gluteal muscle mass with the finger tips on the hamstrings. • The practitioner, who is observing not palpating, stands in front of the person and toward the head • The person is asked to raise his leg into extension as end of the table. the practitioner assesses the firing sequence. • The person is asked to slowly raise the leg into • The normal activation sequence is 0 ) gluteus abduction. maximus, (2) hamstrings, followed by (3) erector spinae contralateral, then (4) ipsilateral. (Note: not all • Normal is represented by pure hip abduction to 45°. clinicians agree with this sequence definition; some Abnormal is represented by: believe hamstrings fire first or that there should be a simultaneous contraction of hamstrings and gluteus 1 . hip flexion during abduction, indicating tensor maximus.) fasciae latae (TFL) shortness, and / or • If the hamstrings and /or erectors take on the role of 2. the leg externally rotating during abduction, gluteus maximus as the prime mover, they will indicating piriformis shortness, and/or become shortened and further inhibit gluteus maximus. 3. 'hip hiking' (crest of ilium elevates cranially), • Janda (1 996) says: 'The poorest pattern occurs when indicating quadratus lumborum shortness (and the erector spinae on the ipsilateral side, or even the probable gluteus medius weakness), and /or shoulder girdle muscles, initiate the movement and activation of gluteus maximus is weak and 4. posterior pelvic rotation, suggesting short antagonistic hip adductors. Figure 11. 17 Hip abduction test which, if normal, occurs without 'hip hike', hip flexion or external rotation (reproduced with permission from Chaitow & DeLany 2000).

THE PELVIS 323 Variation 1 In the case of reflexly induced weakness, a degree of reeducation and rehabilitation is usually required to • Before the test is performed the practitioner (standing encourage more normal coordinated patterns of use, once behind the sidelying patient) lightly places the finger causative factors - such as myofascial trigger point tips of the cephalad hand onto the lateral margin of activity or joint restriction - have been eliminated. There quadratus lumborum while also placing the caudal are clearly different perspectives as to priorities in hand so that the heel is on gluteus medius and the treating such dysfunction, with one body of thought finger tips on TFL. maintaning that normalization of joint restriction is a priority (a largely chiropractic perspective). For example, • If quadratus lumborum is overactive (and, by Liebenson ( 1 996) suggests that joint mobilization should implication, shortened), it will fire before gluteus and precede muscle relaxation methods, while others believe possibly before TFL. that normalization of any muscular/ ligamentous features deserves priority (Kuchera 1997). It seems • The indication would be that quadratus (and possibly possible that both points of view are correct in different TFL) had shortened and that gluteus medius is circumstances. The practitioner is best guided by keen inhibited. observation of the response of the patient's body when a particular order is applied and should change that order Variation 2 (or the modality choice) when a satisfactory outcome is not fairly consistently achieved. • When observing the abduction of the hip, there should be a sense of 'hinging' occurring at the hip Strength and stamina testing for gluteus and not at waist level. maximus and medius • If there is a definite sense of the hinge being in the Lee (1 997), Liebenson (2001 ) and Norris (2000) describe low back/waist area, the implication is the same as in strength (or, more accurately, endurance) tests for gluteus variation 1 - that quadratus is overactive and medius and maximus. shortened, while gluteus medius is inhibited and weak. Gluteus medius Tests for weakness Method 1 Simons et al (1 999) suggest that weakness needs to be • The patient is sidelying, leg to be tested is uppermost evaluated both statically and dynamically. In static with knee extended. testing, a single muscle is being evaluated as the patient attempts a voluntary contraction and this process is • The hip is placed and supported in slight extension, under cortical control. In dynamic testing, which involves abduction and external rotation and the patient is muscular effort relative to a normal functional movement asked to maintain the position of the trunk and leg and where a degree of coordinated muscular effort is when support for the leg is released. required, there is a greater degree of 'vulnerability to reflex inhibition' (Simons et al 1 999), for example, involving • When the support is released and if gluteus medius is trigger points. Dynamic activity is under less direct weak, there may be posterior pelvic rotation or the cortical control and often involves coordinated patterns spine may be pulled into sideflexion as quadratus of integrated neural and muscular function which are lumborum attempts to brace the leg. semi-automatic, largely under cerebellar control. Key differences in these testing methods are as follows. • If the patient can maintain the original position for 1 0 seconds, pressure is then applied to the leg in the A muscle which is being statically loaded may direction of hip flexion, adduction and internal suddenly quit because of pain in an associated stabilizer rotation, thereby resisting gluteus medius posterior or in the muscle itself. This may relate to a variety of fibers. dysfunctional possibilities ranging from inflammation to trigger point activity. The cessation of effort during a • If the posterior fibers of gluteus medius are weak, the static test may occur just prior to the point at which pain patient will be unable to hold the position against would be noted and may be a learned response. Simons pressure. et al (1 999) suggest that the location and degree of pain associated with this kind of test can 'help to locate the • If weakness is established, the implications for 51 inhibiting trigger points'. The deactivation of such points joint instability during the gait cycle are clear. is capable of rapidly normalizing strength in such Reasons for the relative weakness should be assessed, muscles once the inhibiting factor ceases. which could possibly involve excess tone in

324 CLIN I CAL APPLICATION OF NMT VOLUME 2 antagonists or trigger points in gluteus medius or stamina of gluteus medius rather than its initial associated muscles. • Special attention should be given to searching for strength. trigger points in those muscles which refer into the • The standing patient is instructed to shift from two­ gluteus medius region, such as quadratus lumborum, gluteus maximus and minimus, iliocostalis leg to one-leg support while standing on the leg lumborum, piriformis, and rectus abdominis. being tested. • The pelvis should remain relatively level and not Method 2 (Norris 2000) shift more than 1 inch (2.5 cm) toward the weight­ • The patient is sidelying with lower leg straight and bearing side within the first 20 seconds of single-leg upper leg (to be tested) flexed at hip and knee, so that the medial aspect of the foot rests on the table standing. surface just distal to and posterior to the contralateral • The position is held for 20 seconds and the following knee. indications of gluteus medius weakness should be • The hip is passively externally rotated so that the foot evaluated: gluteus medius is weak if greater than 1 now rests with the sole on the floor, at which time the inch (2.5 cm) side shift occurs before 20 seconds or if patient is asked to maintain that position, involving pelvic unleveling occurs before 20 seconds. gluteus medius in a stabilizing task in its inner range. Gluteus maximus • Optimal endurance is indicated by an ability to maintain this position for 1 0-20 seconds. Method 1 • If endurance is poor a holding time of less than The patient is prone and is requested to contract the 10 seconds will be evident and if the limb drops away buttocks, squeezing them together, as they are palpated. from the imler range position immediately, a A strong bilateral contraction should be noted. lengthened and very weak gluteus medius is probable. Method 2 (Lee 1 999) Method 3 • The patient is then asked to extend one hip (no greater than 1 0°) willie the ipsilateral knee is flexed to 90°. • The Trendelenburg test evaluates gluteus medius strength. • The practitioner offers some counterpressure to the extended thigh to assess its stability. • The patient stands and the sacral dimples (which should be level) are observed and their relative • If the patient introduces extension of the lumbar height to each other noted so that their behavior spine to assist the stabilization effort, there is an during the subsequent test can be accurately implication of relative gluteus maximus weakness. monitored. This example will test the right side. • Reasons for the relative weakness should be • The patient stands on the right leg and the gluteus established, possibly involving excess tone in medius should contract, thereby sidebending the antagonists, trigger points in associated muscles or pelvis on the right side which results in elevation of nerve root lesions. the pelvis on the left side (i.e. the right sacral dimple should move inferiorly). If this happens the test is Method 3 (Norris 2000) negative (i.e. the muscle is behaving normally). • To assess stamina of gluteus maximus, the prone • If the muscle is inadequate to the task of sidebending patient's leg, flexed at the knee, is taken into the pelvis (i.e. sacral dimples stay level or the left extension to between 5° and 1 0° and the patient is sacral dimple drops), the test is positive and asked to hold this. gluteus medius is assumed to be weak or not functioning. • Optimal endurance is indicated when this full inner range stabilizing task can be maintained for 1 0-20 • The reasons for this dysfunction should be seconds. investigated and might include pathologies which bring the attachments close to each other (fractures of • If endurance is poor a holding time of less than 1 0 the greater trochanter, slipped capital femoral seconds will b e evident and if the limb drops away epiphysis), congenital dislocation, poliomyelitis or from the inner range position immediately, a nerve root lesions (Hoppenfeld 1 976). lengthened and very weak gluteus maximus is probable. Method 4 ( Liebenson 2001 ) Strength testing for piriformis • This variation on the previous test evaluates the Travell & Simons (1 992) describe the Pace abduction test which can be used to test for strength of the piriformis. It appears here with minor modifications.